Original Research

@article{saadi_disparate_2025,

title = {Disparate Use of Diagnostic Modalities for Patients With Limited English Proficiency and Neurologic Disorders.},

author = {Altaf Saadi and Redwan Bin Abdul Baten and Margarita Alegría and David Himmelstein and Steffie Woolhandler},

doi = {10.1212/CPJ.0000000000200417},

issn = {2163-0402 2163-0933},

year  = {2025},

date = {2025-04-01},

journal = {Neurology. Clinical practice},

volume = {15},

number = {2},

pages = {e200417},

abstract = {BACKGROUND AND OBJECTIVES: Limited English proficiency (LEP) impairs health access-including outpatient specialty care-and quality care, i.e., inappropriate use of diagnostic tests. At least in some cases, studies have suggested that clinicians may substitute testing for time-consuming clinical evaluation involving medical interpreters. This study (1) examines disparities in receipt of diagnostic testing among patients with LEP and neurologic illness, in both the ambulatory and emergency department (ED) settings, including (2) whether better patient-provider communication is associated with reduced testing disparities and (3) how testing disparities vary according to insurance. METHODS: We analyzed nationally representative data from the 2003-2018 Medical Expenditure Panel Survey and identified adults with neurologic illness using diagnostic codes. To assess the association between LEP status and diagnostic testing (CT/MRI, laboratory tests, and any diagnostic tests), we estimated logistic regression models that included year-fixed effects. We constructed separate models for ambulatory and ED settings, including models with a patient-provider communication measure to see how that influenced the LEP-diagnostic testing association. Finally, we conducted stratified analyses by sources of health insurance. RESULTS: LEP status was associated with greater receipt of laboratory tests (OR = 1.46, p < 0.05) but less CT/MRI in the ambulatory setting (0.86, p < 0.05), patterns that persisted in analyses stratified by insurance status. Factoring in patient-provider communication attenuated but did not eliminate these disparities, with attenuation most notable in rates of CT/MRI. We found fewer testing disparities for patients with LEP in the ED than in ambulatory settings. DISCUSSION: In this nationwide study of patients with neurologic illness, we observed both greater and less use of diagnostic tests for patients with LEP and neurologic illness. The greater use of laboratory tests may reflect the overuse of easily obtainable tests for patients with LEP. Conversely, the less use of CT/MRI may be due to time and transportation challenges in scheduling follow-up visits, alongside other barriers to patient follow-up. The population of patients with LEP is growing, making it critical to study not only disparities in their care but also nuances and determinants of these disparities beyond patient-provider communication and across clinical settings.},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{cai_use_2025,

title = {Use and Costs of Supplemental Benefits in Medicare Advantage, 2017-2021.},

author = {Christopher L. Cai and Sonia Iyengar and Steffie Woolhandler and David U. Himmelstein and Kavya Kannan and Lisa Simon},

doi = {10.1001/jamanetworkopen.2024.54699},

issn = {2574-3805},

year  = {2025},

date = {2025-01-01},

journal = {JAMA network open},

volume = {8},

number = {1},

pages = {e2454699},

abstract = {IMPORTANCE: Nearly all Medicare Advantage (MA) plans offer dental, vision, and hearing benefits not covered by traditional Medicare (TM). However, little is known about MA enrollees' use of those benefits or how much they cost MA insurers or enrollees. OBJECTIVE: To estimate use, out-of-pocket (OOP) spending, and insurer payments for dental, hearing, and vision services among Medicare beneficiaries. DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional analysis used pooled 2017-2021 Medical Expenditure Panel Survey (MEPS) and Medicare Current Beneficiary Survey (MCBS) data for MA and TM beneficiaries (excluding those also covered by Medicaid). The analysis was performed from September 10, 2023, to June 30, 2024. EXPOSURES: MA compared with TM coverage. MAIN OUTCOMES AND MEASURES: The main outcome was receipt of eye examinations, corrective lenses, hearing aids, optometry and dental visits, and MA and TM enrollees' and insurers' spending for such services. MEPS and MCBS data were weighted to be nationally representative. RESULTS: We included 76 557 non-dually eligible Medicare beneficiaries, including 23 404 from the MEPS and 53 153 from the MCBS. Weighted demographic characteristics of MA and TM beneficiaries were similar (54.7% and 51.9% female; 39.8% and 35.2% older than 75 years, respectively). Only 54.2% (95% CI, 52.4%-55.9%) and 54.3% (95% CI 52.2%-56.3%) of MA beneficiaries were aware of having MA dental and vision coverage, respectively. MA enrollees were no more likely to receive eye examinations, hearing aids, or eyeglasses than TM enrollees. After adjustment for demographic differences, MA and TM enrollees paid OOP $205.86 (95% CI, $192.44-$219.27) and $226.12 (95% CI, $212.02-$240.23), respectively, for eyeglasses (MA - TM difference, -$20.27 [95% CI, -$33.77 to -$6.77] or -9.0% [95% CI, -14.9% to -3.0%]); $226.82 (95% CI, $202.24-$251.40) and $249.98 (95% CI, $226.22-$273.74) for dental visits, respectively (MA - TM difference, -$23.16 [95% CI, -$43.15 to -$3.17] or -9.3% [95% CI, -17.3% to -1.3%]); and no less for optometry visits or durable medical equipment (a proxy for hearing aids). Nationwide, MA plans' annual spending on vision, dental services, and durable medical equipment totaled $3.9 billion (95% CI, $3.3-$4.4 billion), while enrollees spent OOP $9.2 billion (95% CI, $8.2-$10.2 billion) annually for these services and other private insurers covered $2.8 billion (95% CI, $2.7-$3.0 billion). CONCLUSIONS AND RELEVANCE: In this cross-sectional study of 2 nationally representative surveys, MA beneficiaries did not receive more supplemental services than TM beneficiaries, possibly because of cost-sharing and limited awareness of benefit coverage.},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{gaffney_demand_2025,

title = {Demand and Supply Drivers of Medicare and Non-Medicare Health Spending: An Analysis of UṠ. States, 1991-2019.},

author = {Adam Gaffney and Danny McCormick and Gracie Himmelstein and Steffie Woolhandler and David U. Himmelstein},

doi = {10.1177/27551938241258399},

issn = {2755-1946 2755-1938},

year  = {2025},

date = {2025-01-01},

journal = {International journal of social determinants of health and health services},

volume = {55},

number = {1},

pages = {55–63},

abstract = {For the last four decades, policymakers have attempted to control the United States's high health care costs by reducing patients' demand for care (e.g., by imposing managed-care restrictions or high costs on patients at the time of use). Yet studies based mostly on data from the public Medicare program, which covers mostly elderly Americans, suggest that supply (e.g., number of physicians or hospital beds) rather than demand drives aggregate service use and, hence, costs. Using variation between U.S. states in per enrollee Medicare spending versus per capita spending of all other (non-Medicare) individuals, we find that greater supply boosts costs for the entire population. Furthermore, we find that factors that suppress demand in the non-Medicare population do reduce non-Medicare health care spending, but simultaneously increase Medicare spending. This suggests that for a given supply of medical resources, suppressing demand for one group of patients may produce a compensatory increase in provision of care to those whose demand has not been suppressed. Health planning to assure adequate medical resources where they are needed while preventing excess supply where it is duplicative and wasteful is likely a more effective cost control strategy than the imposition of managed-care restrictions or imposing higher costs onto patients seeking care.},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{schrier_hospital_2025,

title = {Hospital Assets and Private Equity Acquisition-Reply.},

author = {Elizabeth Schrier and Hope E. M. Schwartz and Steffie Woolhandler},

doi = {10.1001/jama.2024.23424},

issn = {1538-3598 0098-7484},

year  = {2025},

date = {2025-01-01},

journal = {JAMA},

volume = {333},

number = {3},

pages = {257–258},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{lupez_cross-sectional_2025,

title = {Cross-Sectional Evaluation of State-Level Protections, Medical Debt, and Deferred Care Among Sexual and Gender Minority People.},

author = {Emily Lupton Lupez and Steffie Woolhandler and David U. Himmelstein and Samuel Dickman and Elizabeth Schrier and Lenore S. Azaroff and Chris Cai and Danny McCormick},

doi = {10.1007/s11606-024-09258-9},

issn = {1525-1497 0884-8734},

year  = {2025},

date = {2025-01-01},

journal = {Journal of general internal medicine},

abstract = {BACKGROUND: Millions of Americans have medical debt and/or defer care due to cost. Few studies have examined the association of such health-related financial problems with sexual orientation or gender identity, and whether state-level policies protecting sexual and gender minority (SGM) people affect disparities in such problems. OBJECTIVE: To examine the relationships between SGM status, state-level SGM protections, and health-related financial problems. DESIGN: Cross-sectional analysis. PARTICIPANTS: Nationally-representative sample of U.S. adults in the 2021 National Financial Capability Study. MAIN MEASURES: Prevalence of medical debt and/or deferred care; adjusted odds ratios (aORs) by SGM status and residence in a state with fewer SGM protections. KEY RESULTS: Of 25,170 survey respondents, 3.7% were gay/bisexual men, 4.3% lesbian/bisexual women, and 0.6% transgender people. Among lesbian/bisexual women, 39.4% had medical debt, the highest proportion of any group. Accounting for sociodemographic and personal-financial factors, women and all lesbian/gay/bisexual persons (vs. straight men) more often experienced medical debt (aOR [95% CI]: straight women 1.28 [1.16, 1.41], gay/bisexual men 1.55 [1.23, 1.94], lesbian/bisexual women 1.80 [1.50, 2.10]) or deferred care (e.g., 1.80 [1.51, 2.16] for lesbian/bisexual women). Transgender people vs. cisgender men were more likely to defer care (aOR = 2.58 [1.54, 4.30]). Living in a state with fewer SGM protections was associated with higher rates of health-related financial problems for most groups, especially cisgender women and lesbian/bisexual women. CONCLUSIONS: Lesbian/gay/bisexual, female, and transgender adults experience more health-related financial problems, especially in states lacking SGM protections, underlining the importance of universal, comprehensive insurance coverage (including for services unique to SGM people), ending bans on gender-affirming care, and closing the male-female pay gap.},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{azaroff_job_2025,

title = {Job Lock and Parents of Children With Cystic Fibrosis.},

author = {Lenore S. Azaroff and Steffie Woolhandler and Danny McCormick and David U. Himmelstein and David Bor and Samuel Dickman and Adam Gaffney},

doi = {10.1001/jamapediatrics.2024.4435},

issn = {2168-6211 2168-6203},

year  = {2025},

date = {2025-01-01},

journal = {JAMA pediatrics},

volume = {179},

number = {1},

pages = {99–101},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{mateo_theory_2024,

title = {From Theory to Action: Evaluation of a Longitudinal Project-Based Antiracism Course for Post-Graduate Physicians.},

author = {Camila M. Mateo and Danny McCormick and Chrissie Connors and Gaurab Basu},

doi = {10.1177/23821205241303643},

issn = {2382-1205},

year  = {2024},

date = {2024-12-01},

journal = {Journal of medical education and curricular development},

volume = {11},

pages = {23821205241303643},

abstract = {OBJECTIVES: Few opportunities exist for postgraduate physicians to learn to address racism in their professional practice. We created a virtual, 5-session antiracism course that included the development of a formal action project to address racism at participants' home institution. METHODS: We delivered this curriculum virtually to 2 cohorts (2021 and 2022) of postgraduate physicians, nationally. The curriculum had 3 educational aims: (1) to increase knowledge on antiracism, (2) to increase comfort and engagement in discussing antiracism at home institutions, and (3) to increase self-efficacy to execute an institution-based project. Theory-informed practice, community building, and project-based learning were used to achieve our educational aims. We analyzed changes in these domains in addressing racism using matched 7-item Likert-scale questions from pre- and post-course surveys and the Wilcoxon signed rank test. We assessed perceptions and impacts of the course with post-course survey items using descriptive statistics. RESULTS: Forty-three of 50 participants (86%) who completed pre- and post-course surveys were included in the analysis. We found pre-post course increases in mean scores (converted from Likert scales), for all 15 paired questions. For example, we found improvements in understanding the historical context of racism in medical institutions (mean score change: 5.12 [SD 1.00] to 6.42 [SD 0.76], P < .001), comfort in talking to colleagues about racism (5.21 [SD 1.08] to 6.19 [SD 0.70], P < .001), and capacity to address racism in patient care at their home institution (4.51 [SD 1.35] to 5.56 [SD 0.91], P < 0.001). 93% reported the course increased the likelihood of working to address racism at their institution. CONCLUSION: This project-based antiracism course for postgraduate learners increased self-reported knowledge of, comfort with, and self-efficacy in addressing racism and was well received by participants.},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{de_guzman_reply_2024,

title = {Reply to Comments on Health Care Access and COVID-19 Vaccination in the United States.},

author = {Charles De Guzman and Danny McCormick and Adam Gaffney},

doi = {10.1097/MLR.0000000000002060},

issn = {1537-1948 0025-7079},

year  = {2024},

date = {2024-12-01},

journal = {Medical care},

volume = {62},

number = {12},

pages = {840–841},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{gaffney_respiratory_2024,

title = {Respiratory Syncytial Virus (RSV) Vaccine Uptake Among Older Adults: a Population-Based Study of Massachusetts Towns.},

author = {Adam Gaffney and David U. Himmelstein and Danny McCormick and Steffie Woolhandler},

doi = {10.1007/s11606-024-08999-x},

issn = {1525-1497 0884-8734},

year  = {2024},

date = {2024-11-01},

journal = {Journal of general internal medicine},

volume = {39},

number = {15},

pages = {3096–3098},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{gaffney_age_2024,

title = {Age of Emergence of Disparities in Asthma Prevalence and Morbidity among US Children.},

author = {Adam Gaffney and Danny McCormick and David Bor and David U. Himmelstein and Steffie Woolhandler},

doi = {10.1513/AnnalsATS.202310-916OC},

issn = {2325-6621},

year  = {2024},

date = {2024-10-01},

journal = {Annals of the American Thoracic Society},

abstract = {RATIONALE: Early-life exposures may precipitate asthma, but their contribution to disparities in asthma is less clear. OBJECTIVE: To elucidate racial, ethnic, and socioeconomic status (SES) disparities in the age trajectory of asthma burden among US children. METHODS: We analyzed three datasets: (1) 2016-2021 National Children's Health Survey (NCHS) (n=223,551); (2) 2015-2017 Child Asthma Call-Back Survey (ACBS) (n=4,289); and (3) 2018-2019 National Inpatient Sample (NIS) (n=23,713 children with asthma). We examined cumulative asthma prevalence by individual-year of age and children's race and ethnicity or SES (NCHS); mean age at asthma diagnosis by race and ethnicity and SES, unadjusted and adjusted for confounders (ACBS); and asthma hospitalization rates overall and per child with asthma by individual year of age and race and ethnicity (NIS). RESULTS: Among White children, cumulative asthma prevalence rises gradually through childhood, to 6.6% at age 5 and 16.1% by age 17. Prevalence rises more sharply in early childhood among Black children, reaching 17.6% at age 5 (RR 2.6;95%CI 1.9,3.8), but plateaus after age 9, with a consequent decline in Black-White relative disparities into adolescence. Disparities according to SES follow a similar trajectory, emerging early and subsequently narrowing. Similarly, Black, Hispanic and low-income children with asthma are diagnosed at an earlier age than White (or high-income) children. The asthma hospitalization rate rises in the first years of life among all children, but most rapidly among Black children, with a peak absolute Black-White gap at age 4; the relative gap remains wide throughout childhood and peaks at age 10. However, per child with asthma, relative disparities in White-Black hospitalizations rise through age 15. CONCLUSIONS: Disparities in asthma prevalence emerge in early childhood and then narrow, suggesting that reducing early-life adverse environmental exposures may be key to asthma prevention. Policies to improve the social determinants of health during gestation and childhood, e.g. environmental equity and family income support, are needed.},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{schrier_taxpayers_2024,

title = {Taxpayers' Share of US Prescription Drug and Insulin Costs: a Cross-Sectional Study.},

author = {Elizabeth Schrier and David U. Himmelstein and Adam Gaffney and Danny McCormick and Steffie Woolhandler},

doi = {10.1007/s11606-024-09032-x},

issn = {1525-1497 0884-8734},

year  = {2024},

date = {2024-10-01},

journal = {Journal of general internal medicine},

abstract = {BACKGROUND: Drug prices affect government budgets directly through spending on public programs like Medicare and Medicaid, and indirectly via private coverage for public employees and tax subsidies for private insurance. Yet, the Senate parliamentarian ruled that the Senate could not use streamlined Budget Reconciliation to extend the Inflation Reduction Act's controls on insulin co-payment or drug prices to private insurers on the grounds that their expenditures do not affect the federal budget. OBJECTIVE: To quantify insulin and other drug costs borne by federal, state, and local governments, including direct expenditures and indirect government subsidies that flow through private insurers. DESIGN: Cross-sectional analysis of expenditures for outpatient retail prescription drugs reported by respondents and their pharmacies in the 2019 Medical Expenditure Panel Survey (adjusted downward for drug rebates), supplemented with information on employment-related insurance from the US Office of Management and Budget and other sources. PARTICIPANTS: The civilian non-institutionalized US population. MAIN MEASURES: Direct (payments by public health insurance programs) and indirect (taxpayer-funded payments via private insurers) government expenditures for outpatient retail drugs. KEY RESULTS: Direct government expenditures for outpatient retail prescription drugs totaled $154.85 billion in 2019, including $15.68 billion for insulin. Indirect government expenditures channeled through private insurers totaled $53.59 billion (including $5.48 billion for insulins). Those indirect expenditures encompassed $32.32 billion in tax subsidies for employer-sponsored private coverage, $25 million for subsidies to private Affordable Care Act marketplace plans, and $21.24 billion for government-paid premiums for public employees and retirees. Overall, government expenditures for outpatient retail prescription drugs totaled $208.44 billion, 58.76% of all-payer spending and 65.96% of spending for insulin. CONCLUSIONS: Governments directly or indirectly fund most drug purchases, including substantial expenditures that flow through private insurers. Hence, prices paid by private insurers impact government budgets, supporting the view that government should be allowed to regulate drug prices.},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{lupez_health_2024,

title = {Health, Access to Care, and Financial Barriers to Care Among People Incarcerated in US Prisons.},

author = {Emily Lupton Lupez and Steffie Woolhandler and David U. Himmelstein and Laura Hawks and Samuel Dickman and Adam Gaffney and David Bor and Elizabeth Schrier and Chris Cai and Lenore S. Azaroff and Danny McCormick},

doi = {10.1001/jamainternmed.2024.3567},

issn = {2168-6114 2168-6106},

year  = {2024},

date = {2024-10-01},

journal = {JAMA internal medicine},

volume = {184},

number = {10},

pages = {1176–1184},

abstract = {IMPORTANCE: Decades-old data indicate that people imprisoned in the US have poor access to health care despite their constitutional right to care. Most prisons impose co-payments for at least some medical visits. No recent national studies have assessed access to care or whether co-pays are associated with worse access. OBJECTIVE: To determine the proportion of people who are incarcerated with health problems or pregnancy who used health services, changes in the prevalence of those conditions since 2004, and the association between their state's standard prison co-payment and care receipt in 2016. DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional analysis was conducted in October 2023 and used data from the Bureau of Justice Statistics' 2016 Survey of Prison Inmates, a nationally representative sample of adults in state or federal prisons, with some comparisons to the 2004 version of that survey. EXPOSURES: The state's standard, per-visit co-payment amount in 2016 compared with weekly earnings at the prison's minimum wage. MAIN OUTCOMES AND MEASURES: Self-reported prevalence of 13 chronic physical conditions, 6 mental health conditions, and current severe psychological distress assessed using the Kessler Psychological Distress Scale; proportion of respondents with such problems who did not receive any clinician visit or treatment; and adjusted odds ratios (aORs) comparing the likelihood of no clinician visit according to co-payment level. RESULTS: Of 1 421 700 (unweighted: n = 24 848; mean [SD] age, 35.3 [0.3] years; 93.2% male individuals) prison residents in 2016, 61.7% (up from 55.9% in 2004) reported 1 or more chronic physical conditions; among them, 13.8% had received no medical visit since incarceration. A total of 40.1% of respondents reported ever having a mental health condition (up from 24.5% in 2004), of whom 33.0% had received no mental health treatment. A total of 13.3% of respondents met criteria for severe psychological distress, of whom 41.7% had not received mental health treatment in prison. Of state prison residents, 90.4% were in facilities requiring co-payments, including 63.3% in facilities with co-payments exceeding 1 week's prison wage. Co-payments, particularly when high, were associated with not receiving a needed health care visit (co-pay ≤1 week's wage: aOR, 1.43; 95% CI, 1.10-1.86; co-pay >1 week's wage: aOR, 2.17; 95% CI, 1.61-2.93). CONCLUSIONS AND RELEVANCE: This cross-sectional study found that many people who are incarcerated with health problems received no care, particularly in facilities charging co-payments for medical visits.},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{cortes_eliciting_2024,

title = {Eliciting patient past experiences of healthcare discrimination as a potential pathway to reduce health disparities: A qualitative study of primary care staff.},

author = {Dharma E. Cortés and Ana M. Progovac and Frederick Lu and Esther Lee and Nathaniel M. Tran and Margo A. Moyer and Varshini Odayar and Caryn R. R. Rodgers and Leslie Adams and Valeria Chambers and Jonathan Delman and Deborah Delman and Selma Castro and María José Sánchez Román and Natasha A. Kaushal and Timothy B. Creedon and Rajan A. Sonik and Catherine Rodriguez Quinerly and Ora Nakash and Afsaneh Moradi and Heba Abolaban and Tali Flomenhoft and Ruth Nabisere and Ziva Mann and Sherry Shu-Yeu Hou and Farah N. Shaikh and Michael W. Flores and Dierdre Jordan and Nicholas Carson and Adam C. Carle and Benjamin Lé Cook and Danny McCormick},

doi = {10.1111/1475-6773.14373},

issn = {1475-6773 0017-9124},

year  = {2024},

date = {2024-08-01},

journal = {Health services research},

pages = {e14373},

abstract = {OBJECTIVE: To understand whether and how primary care providers and staff elicit patients' past experiences of healthcare discrimination when providing care. DATA SOURCES/STUDY SETTING: Twenty qualitative semi-structured interviews were conducted with healthcare staff in primary care roles to inform future interventions to integrate data about past experiences of healthcare discrimination into clinical care. STUDY DESIGN: Qualitative study. DATA COLLECTION/EXTRACTION METHODS: Data were collected via semi-structured qualitative interviews between December 2018 and January 2019, with health care staff in primary care roles at a hospital-based clinic within an urban safety-net health system that serves a patient population with significant racial, ethnic, and linguistic diversity. PRINCIPAL FINDINGS: Providers did not routinely, or in a structured way, elicit information about past experiences of healthcare discrimination. Some providers believed that information about healthcare discrimination experiences could allow them to be more aware of and responsive to their patients' needs and to establish more trusting relationships. Others did not deem it appropriate or useful to elicit such information and were concerned about challenges in collecting and effectively using such data. CONCLUSIONS: While providers see value in eliciting past experiences of discrimination, directly and systematically discussing such experiences with patients during a primary care encounter is challenging for them. Collecting this information in primary care settings will likely require implementation of multilevel systematic data collection strategies. Findings presented here can help identify clinic-level opportunities to do so.},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{schrier_hospital_2024,

title = {Hospital Assets Before and After Private Equity Acquisition.},

author = {Elizabeth Schrier and Hope E. M. Schwartz and David U. Himmelstein and Adam Gaffney and Danny McCormick and Samuel L. Dickman and Steffie Woolhandler},

doi = {10.1001/jama.2024.13555},

issn = {1538-3598 0098-7484},

year  = {2024},

date = {2024-08-01},

journal = {JAMA},

volume = {332},

number = {8},

pages = {669–671},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{tobin-tyler_rape_2024,

title = {Rape, Homicide, and Abortion Bans - The Abandonment of People Subjected to Sexual and Intimate Partner Violence.},

author = {Elizabeth Tobin-Tyler and Samuel L. Dickman},

doi = {10.1056/NEJMp2405254},

issn = {1533-4406 0028-4793},

year  = {2024},

date = {2024-07-01},

journal = {The New England journal of medicine},

volume = {391},

number = {4},

pages = {289–292},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{gaffney_hospital_2024,

title = {Hospital Capital Assets, Community Health, and the Utilization and Cost of Inpatient Care: A Population-Based Study of US Counties.},

author = {Adam Gaffney and Danny McCormick and David Bor and Steffie Woolhandler and David U. Himmelstein},

doi = {10.1097/MLR.0000000000001999},

issn = {1537-1948 0025-7079},

year  = {2024},

date = {2024-06-01},

journal = {Medical care},

volume = {62},

number = {6},

pages = {396–403},

abstract = {BACKGROUND: The provision of high-quality hospital care requires adequate space, buildings, and equipment, although redundant infrastructure could also drive service overprovision. OBJECTIVE: To explore the distribution of physical hospital resources-that is, capital assets-in the United States; its correlation with indicators of community health and nonhealth factors; and the association between hospital capital density and regional hospital utilization and costs. RESEARCH DESIGN: We created a dataset of n=1733 US counties by analyzing the 2019 Medicare Cost Reports; 2019 State Inpatient Database Community Inpatient Statistics; 2020-2021 Area Health Resource File; 2016-2020 American Community Survey; 2022 PLACES; and 2019 CDC WONDER. We first calculated aggregate hospital capital assets and investment at the county level. Next, we examined the correlation between community's medical need (eg, chronic disease prevalence), ability to pay (eg, insurance), and supply factors with 4 metrics of capital availability. Finally, we examined the association between capital assets and hospital utilization/costs, adjusted for confounders. RESULTS: Counties with older and sicker populations generally had less aggregate hospital capital per capita, per hospital day, and per hospital discharge, while counties with higher income or insurance coverage had more hospital capital. In linear regressions controlling for medical need and ability to pay, capital assets were associated with greater hospital utilization and costs, for example, an additional $1000 in capital assets per capita was associated with 73 additional discharges per 100,000 population (95% CI: 45-102) and $19 in spending per bed day (95% CI: 12-26). CONCLUSIONS: The level of investment in hospitals is linked to community wealth but not population health needs, and may drive use and costs.},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{de_guzman_health_2024,

title = {Health Care Access and COVID-19 Vaccination in the United States: A Cross-Sectional Analysis.},

author = {Charles De Guzman and Chloe A. Thomas and Lynn Wiwanto and Dier Hu and Jose Henriquez-Rivera and Lily Gage and Jaclyn C. Perreault and Emily Harris and Charlotte Rastas and Danny McCormick and Adam Gaffney},

doi = {10.1097/MLR.0000000000002005},

issn = {1537-1948 0025-7079},

year  = {2024},

date = {2024-06-01},

journal = {Medical care},

volume = {62},

number = {6},

pages = {380–387},

abstract = {BACKGROUND: Although federal legislation made COVID-19 vaccines free, inequities in access to medical care may affect vaccine uptake. OBJECTIVE: To assess whether health care access was associated with uptake and timeliness of COVID-19 vaccination in the United States. DESIGN: A cross-sectional study. SETTING: 2021 National Health Interview Survey (Q2-Q4). SUBJECTS: In all, 21,532 adults aged≥18 were included in the study. MEASURES: Exposures included 4 metrics of health care access: health insurance, having an established place for medical care, having a physician visit within the past year, and medical care affordability. Outcomes included receipt of 1 or more COVID-19 vaccines and receipt of a first vaccine within 6 months of vaccine availability. We examined the association between each health care access metric and outcome using logistic regression, unadjusted and adjusted for demographic, geographic, and socioeconomic covariates. RESULTS: In unadjusted analyses, each metric of health care access was associated with the uptake of COVID-19 vaccination and (among those vaccinated) early vaccination. In adjusted analyses, having health coverage (adjusted odds ratio [AOR] 1.60; 95% CI: 1.39, 1.84), a usual place of care (AOR 1.58; 95% CI: 1.42, 1.75), and a doctor visit within the past year (AOR 1.45, 95% CI: 1.31, 1.62) remained associated with higher rates of COVID-19 vaccination. Only having a usual place of care was associated with early vaccine uptake in adjusted analyses. LIMITATIONS: Receipt of COVID-19 vaccination was self-reported. CONCLUSIONS: Several metrics of health care access are associated with the uptake of COVID-19 vaccines. Policies that achieve universal coverage, and facilitate long-term relationships with trusted providers, may be an important component of pandemic responses.},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{azaroff_excess_2024,

title = {Excess Infant and Child Deaths 2007-2020 in UṠ. States With Abortion Bans.},

author = {Lenore S. Azaroff and Steffie Woolhandler and Samuel L. Dickman and David Bor and David U. Himmelstein},

doi = {10.1016/j.amepre.2023.12.014},

issn = {1873-2607 0749-3797},

year  = {2024},

date = {2024-05-01},

journal = {American journal of preventive medicine},

volume = {66},

number = {5},

pages = {917–920},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{gaffney_dysfunctional_2024,

title = {Dysfunctional breathing after COVID-19: recognition and ramifications.},

author = {Adam Gaffney},

doi = {10.1183/13993003.00149-2024},

issn = {1399-3003 0903-1936},

year  = {2024},

date = {2024-04-01},

journal = {The European respiratory journal},

volume = {63},

number = {4},

pages = {2400149},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{basu_health_2024,

title = {Health Professionals Organizing for Climate Action: A Novel Community Organizing Fellowship.},

author = {Gaurab Basu and Pedja Stojicic and Anna Goldman and Jonathan Shaffer and Danny McCormick},

doi = {10.1097/ACM.0000000000005637},

issn = {1938-808X 1040-2446},

year  = {2024},

date = {2024-04-01},

journal = {Academic medicine : journal of the Association of American Medical Colleges},

volume = {99},

number = {4},

pages = {408–413},

abstract = {PROBLEM: Climate change is a public health and health equity crisis. Health professionals are well positioned to advance solutions but may lack the training and self-efficacy needed to achieve them. APPROACH: The Center for Health Equity Education and Advocacy at Cambridge Health Alliance, a Harvard Medical School Teaching Hospital, developed a novel, longitudinal fellowship that taught health professionals about health and health equity effects of climate change, as well as community organizing practices that may help them mitigate these effects. The fellowship cohort included 40 fellows organized into 12 teams and was conducted from January to June 2022. Each team developed a project to address climate change and received coaching from an experienced community organizer coach. Effects of the fellowship on participants' knowledge, skills, and attitudes were evaluated using pre- and postfellowship surveys. OUTCOMES: Surveys were analyzed for 38 of 40 (95%) participants who consented to the evaluation and completed both surveys. Surveys used a 7-point Likert scale for item responses. McNemar's test for paired data was used to assess changes in the proportion of respondents who agreed ("somewhat agree"/"agree"/"strongly agree") with statements in pre- vs postfellowship surveys. Statistically significant improvements were found for 11 of the 17 items assessing knowledge, skills, and attitudes. Participants' views of the fellowship and its effects were assessed through additional items in the postfellowship survey. Most respondents agreed that the fellowship increased their knowledge of the connections between climate change and health equity (32/38, 84.2%) and prepared them to effectively participate in a community organizing campaign (37/38, 94.7%). Each of the 12 groups developed climate health projects by the fellowship's end. NEXT STEPS: This novel fellowship was well received and effective in teaching community organizing to health professionals concerned about climate change. Future studies are needed to assess longer-term effects of the fellowship.},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{dickman_rape-related_2024,

title = {Rape-Related Pregnancies in the 14 US States With Total Abortion Bans.},

author = {Samuel L. Dickman and Kari White and David U. Himmelstein and Emily Lupez and Elizabeth Schrier and Steffie Woolhandler},

doi = {10.1001/jamainternmed.2024.0014},

issn = {2168-6114 2168-6106},

year  = {2024},

date = {2024-03-01},

journal = {JAMA internal medicine},

volume = {184},

number = {3},

pages = {330–332},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{gaffney_asthma_2024,

title = {Asthma Disparities in the United States Narrowed During the COVID-19 Pandemic: Findings From a National Survey, 2019 to 2022.},

author = {Adam Gaffney and David U. Himmelstein and Steffie Woolhandler},

doi = {10.7326/M23-2100},

issn = {1539-3704 0003-4819},

year  = {2024},

date = {2024-01-01},

journal = {Annals of internal medicine},

volume = {177},

number = {1},

pages = {103–106},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{kassavin_amputation_2024,

title = {Amputation Rates and Associated Social Determinants of Health in the Most Populous US Counties.},

author = {Daniel Kassavin and Lucas Mota and Claire A. Ostertag-Hill and Monica Kassavin and David U. Himmelstein and Steffie Woolhandler and Sophie X. Wang and Patric Liang and Marc L. Schermerhorn and Sivamainthan Vithiananthan and Moon Kwoun},

doi = {10.1001/jamasurg.2023.5517},

issn = {2168-6262 2168-6254},

year  = {2024},

date = {2024-01-01},

journal = {JAMA surgery},

volume = {159},

number = {1},

pages = {69–76},

abstract = {IMPORTANCE: Social Determinants of Health (SDOH) have been found to be associated with health outcome disparities in patients with peripheral artery disease (PAD). However, the association of specific components of SDOH and amputation has not been well described. OBJECTIVE: To evaluate whether individual components of SDOH and race are associated with amputation rates in the most populous counties of the US. DESIGN, SETTING, AND PARTICIPANTS: In this population-based cross-sectional study of the 100 most populous US counties, hospital discharge rates for lower extremity amputation in 2017 were assessed using the Healthcare Cost and Utilization Project State Inpatient Database. Those data were matched with publicly available demographic, hospital, and SDOH data. Data were analyzed July 3, 2022, to March 5, 2023. MAIN OUTCOME AND MEASURES: Amputation rates were assessed across all counties. Counties were divided into quartiles based on amputation rates, and baseline characteristics were described. Unadjusted linear regression and multivariable regression analyses were performed to assess associations between county-level amputation and SDOH and demographic factors. RESULTS: Amputation discharge data were available for 76 of the 100 most populous counties in the United States. Within these counties, 15.3% were African American, 8.6% were Asian, 24.0% were Hispanic, and 49.6% were non-Hispanic White; 13.4% of patients were 65 years or older. Amputation rates varied widely, from 5.5 per 100 000 in quartile 1 to 14.5 per 100 000 in quartile 4. Residents of quartile 4 (vs 1) counties were more likely to be African American (27.0% vs 7.9%, P < .001), have diabetes (10.6% vs 7.9%, P < .001), smoke (16.5% vs 12.5%, P < .001), be unemployed (5.8% vs 4.6%},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{woolhandler_administrations_2024,

title = {Administration's Share of Personnel in Veterans Health Administration and Private Sector Care.},

author = {Steffie Woolhandler and Andrew Toporek and Jian Gao and Eileen Moran and Andrew Wilper and David U. Himmelstein},

doi = {10.1001/jamanetworkopen.2023.52104},

issn = {2574-3805},

year  = {2024},

date = {2024-01-01},

journal = {JAMA network open},

volume = {7},

number = {1},

pages = {e2352104},

abstract = {IMPORTANCE: Health care administrative overhead is greater in the US than some other nations but has not been assessed in the Veterans Health Administration (VHA). OBJECTIVE: To compare administrative staffing patterns in the VHA and private (non-VHA) sectors. DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study was conducted using US employment data from 2019, prior to pandemic-related disruptions in health care staffing, and was carried out between January 14 and August 10, 2023. A nationally representative sample of federal and nonfederal personnel in hospitals and ambulatory care settings from the American Community Survey (ACS), all employees reported in VHA personnel records, and personnel in health insurance carriers and brokers tabulated by the Bureau of Labor Statistics (BLS) were analyzed. EXPOSURE: VHA vs private sector health care employment, including 397 occupations grouped into 18 categories. MAIN OUTCOME AND MEASURE: The proportion of staff working in administrative occupations. RESULTS: Among 3 239 553 persons surveyed in the ACS, 122 315 individuals (weighted population, 12 501 185 individuals) were civilians working in hospitals or ambulatory care; of the weighted population, 12 156 988 individuals (mean age, 42.6 years [95% CI, 42.5-42.7 years]; 76.2% [95% CI, 75.9%-76.5%] females) were private sector personnel and 344 197 individuals (mean age, 46.2 years [95% CI, 45.7-46.7 years]; 63.8% [95% CI, 61.8%-65.8%] females) were federal employees. In clinical settings, administrative occupations accounted for 23.4% (95% CI, 23.1%-23.8%) of private sector vs 19.8% (95% CI, 18.1%-21.4%) of VHA personnel. After including 1 000 800 employees at private sector health insurers and brokers and 13 956 VHA Central Office personnel with administrative occupations, administration accounted for 3 851 374 of 13 157 788 private sector employees (29.3%) vs 77 500 of 343 721 VHA employees (22.5%). Physicians represented approximately 7% of personnel in the VHA (7.2% [95% CI, 6.1%-8.2%]) and private sector (6.5% [95% CI, 6.3%-6.7%]), while the VHA deployed more registered nurses (23.7% [95% CI, 21.6%-25.8%] vs 21.2% [95% CI, 20.9%-21.5%]) and social service personnel (6.3% [95% CI, 5.4%-7.1%] vs 4.9% [95% CI, 4.7%-5.0%]) than the private sector. CONCLUSIONS AND RELEVANCE: In this study, administrative occupations accounted for a smaller share of personnel in the VHA compared with private sector care, a difference possibly attributable to the VHA's simpler financing system. These findings suggest that if staffing patterns in the private sector mirrored those of the VHA, nearly 900 000 fewer administrative staff might be needed.},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{gaffney_population-level_2023,

title = {Population-level trends in asthma and chronic obstructive pulmonary disease emergency department visits and hospitalizations before and during the coronavirus disease 2019 pandemic in the United States.},

author = {Adam Gaffney and David U. Himmelstein and Steffie Woolhandler},

doi = {10.1016/j.anai.2023.08.016},

issn = {1534-4436 1081-1206},

year  = {2023},

date = {2023-12-01},

journal = {Annals of allergy, asthma & immunology : official publication of the American College of Allergy, Asthma, & Immunology},

volume = {131},

number = {6},

pages = {737–744.e8},

abstract = {BACKGROUND: Previous studies have identified reductions in exacerbations of chronic lung disease in many locales after onset of the coronavirus disease 2019 (COVID-19) pandemic. OBJECTIVE: To evaluate the population-level impacts of COVID-19 on asthma and chronic obstructive pulmonary disease (COPD) exacerbations-with a focus on disadvantaged communities-in the United States. METHODS: We analyzed 2016 to 2020 county-level data on asthma and COPD acute care use, with myocardial infarction hospitalizations as a comparator condition. We linked this with county-level lower respiratory disease mortality data. We calculated rates of emergency department (ED) visits, hospitalizations, and deaths and evaluated changes using linear regressions adjusted for year and county-fixed effects. For a supplementary analysis, we calculated ED visit rates nationwide for asthma, COPD, or any diagnosis using the 2016 to 2020 National Hospital Ambulatory Medical Care Survey. RESULTS: Our county-level data included 685 counties in 13 states. Rates of each outcome fell in 2020. In adjusted analyses, we found large reductions in asthma and COPD ED visit rates (eg, a 21.5 per 10,000-person reduction in COPD ED visits; 95% confidence interval, -23.8 to -19.1), with smaller reductions in hospitalizations and chronic lower respiratory mortality. Disadvantaged communities had mostly higher baseline rates of respiratory morbidity and larger absolute reductions in some outcomes. Among 90,808 ED visits in the National Hospital Ambulatory Medical Care Survey, asthma ED visits/y fell 33% during the pandemic and COPD visits by 51%; overall ED visits fell by only 7%. CONCLUSION: Onset of the COVID-19 pandemic coincided with reductions in acute care utilization for asthma and COPD. Understanding the mechanism of this reduction might inform future efforts to prevent exacerbations.},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{chatillon_access_2023,

title = {Access to care following Planned Parenthood's termination from Texas' Medicaid network: A qualitative study.},

author = {Anna Chatillon and Elsa Vizcarra and Bhavik Kumar and Samuel L. Dickman and Anitra D. Beasley and Kari White},

doi = {10.1016/j.contraception.2023.110141},

issn = {1879-0518 0010-7824},

year  = {2023},

date = {2023-12-01},

journal = {Contraception},

volume = {128},

pages = {110141},

abstract = {OBJECTIVES: This study aimed to explore Planned Parenthood Medicaid patients' experiences getting reproductive health care in Texas after the state terminated Planned Parenthood providers from its Medicaid program in 2021. STUDY DESIGN: Between January and September 2021, we recruited Medicaid patients who obtained care at Planned Parenthood health centers prior to the state termination using direct mailers, electronic messages, community outreach, and flyers in health centers. We conducted baseline and 2-month follow-up semistructured phone interviews about patients' previous experiences using Medicaid at Planned Parenthood and other providers and how the termination affected their care. We qualitatively analyzed the data using the principles of grounded theory. RESULTS: We interviewed 30 patients, 24 of whom completed follow-up interviews. Participants reported that Planned Parenthood reliably accepted different Medicaid plans, worked with patients to ameliorate the structural barriers they face to care, and referred them to other providers as needed. After Planned Parenthood's termination from the Texas Medicaid program, participants faced difficulties accessing care elsewhere, including same-day appointments and on-site medications. Consequences included delayed or forgone reproductive health care, including contraception, and emotional distress. CONCLUSIONS: Planned Parenthood Medicaid patients found it difficult to connect with other providers for reproductive health care and to obtain evidence-based care following the organization's termination from Medicaid. Ensuring all Medicaid patients have freedom to choose providers would improve access to quality contraception and other reproductive health care. IMPLICATIONS: Medicaid-funded reproductive health care access is restricted for people living on low incomes when providers do not reliably accept all Medicaid plans or cannot participate in Medicaid. This situation can lead to lower quality care, delayed or forgone care, and emotional distress.},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{gaffney_hospital_2023,

title = {Hospital Expenditures Under Global Budgeting and Single-Payer Financing: An Economic Analysis, 2021-2030.},

author = {Adam W. Gaffney and David U. Himmelstein and Steffie Woolhandler and James G. Kahn},

doi = {10.1177/27551938231152750},

issn = {2755-1946 2755-1938},

year  = {2023},

date = {2023-10-01},

journal = {International journal of social determinants of health and health services},

volume = {53},

number = {4},

pages = {548–556},

abstract = {U.S. hospitals provide large amounts of low-value care and devote inordinate resources to administration, while some hospitals leverage market power to realize large profits. Meanwhile, many rural and safety net hospitals are financially distressed. The coexistence of waste and want suggests that U.S. hospital financing is neither efficient nor equitable. We model the economic consequences of adopting the mode of hospital payment used in Canada and the U.S. Veterans Health Administration and proposed in the leading congressional single-payer Medicare-for-All bill: global budgeting. Our models assume increased utilization due to expanded and upgraded coverage; gradual reductions in administrative costs from simplified payment; and the elimination of hospital profits, with hospital capital expenditures funded by explicit grants rather than from profits or borrowing. We estimate that non-federal hospital operating budgets will total $17.2 trillion between 2021 and 2030 under current law versus $14.7 trillion under single-payer with global budgeting. This difference reflects $520 billion in foregone profits and $1,984 billion in reduced expenditures on hospital administration; expenditures on clinical operating budgets, however, would be higher than under current law, funded out of profits.},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{cahn_association_2023,

title = {The Association of Childbirth with Medical Debt in the USA, 2019-2020.},

author = {Jordan Cahn and Ayesha Sundaram and Roopa Balachandar and Alexandra Berg and Aaron Birnbaum and Stephanie Hastings and Matthew Makansi and Emily Romano and Ariel Majidi and Danny McCormick and Adam Gaffney},

doi = {10.1007/s11606-023-08214-3},

issn = {1525-1497 0884-8734},

year  = {2023},

date = {2023-08-01},

journal = {Journal of general internal medicine},

volume = {38},

number = {10},

pages = {2340–2346},

abstract = {BACKGROUND: Medical debt affects one in five adults in the USA and may disproportionately burden postpartum women due to pregnancy-related medical costs. OBJECTIVE: To evaluate the association between childbirth and medical debt, and the correlates of medical debt among postpartum women, in the USA. DESIGN: Cross-sectional. PARTICIPANTS: We analyzed female "sample adults" 18-49 years old in the 2019-2020 National Health Interview Survey, a nationally representative household survey. MAIN MEASURES: Our primary exposure was whether the subject gave birth in the past year. We had two family-level debt outcomes: problems paying medical bills and inability to pay medical bills. We examined the association between live birth and medical debt outcomes, unadjusted and adjusted for potential confounders in multivariable logistic regressions. Among postpartum women, we also examined the association between medical debt with maternal asthma, hypertension, and gestational diabetes and several sociodemographic factors. KEY RESULTS: Our sample included n = 12,163 women},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{bor_missing_2023,

title = {Missing Americans: Early death in the United States-1933-2021.},

author = {Jacob Bor and Andrew C. Stokes and Julia Raifman and Atheendar Venkataramani and Mary T. Bassett and David Himmelstein and Steffie Woolhandler},

doi = {10.1093/pnasnexus/pgad173},

issn = {2752-6542},

year  = {2023},

date = {2023-06-01},

journal = {PNAS nexus},

volume = {2},

number = {6},

pages = {pgad173},

abstract = {We assessed how many US deaths would have been averted each year, 1933-2021, if US age-specific mortality rates had equaled the average of 21 other wealthy nations. We refer to these excess US deaths as "missing Americans." The United States had lower mortality rates than peer countries in the 1930s-1950s and similar mortality in the 1960s and 1970s. Beginning in the 1980s, however, the United States began experiencing a steady increase in the number of missing Americans, reaching 622,534 in 2019 alone. Excess US deaths surged during the COVID-19 pandemic, reaching 1,009,467 in 2020 and 1,090,103 in 2021. Excess US mortality was particularly pronounced for persons under 65 years. In 2020 and 2021, half of all US deaths under 65 years and 90% of the increase in under-65 mortality from 2019 to 2021 would have been avoided if the United States had the mortality rates of its peers. In 2021, there were 26.4 million years of life lost due to excess US mortality relative to peer nations, and 49% of all missing Americans died before age 65. Black and Native Americans made up a disproportionate share of excess US deaths, although the majority of missing Americans were White.},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{gaffney_projected_2023,

title = {Projected Health Outcomes Associated With 3 US Supreme Court Decisions in 2022 on COVID-19 Workplace Protections, Handgun-Carry Restrictions, and Abortion Rights.},

author = {Adam Gaffney and David U. Himmelstein and Samuel Dickman and Caitlin Myers and David Hemenway and Danny McCormick and Steffie Woolhandler},

doi = {10.1001/jamanetworkopen.2023.15578},

issn = {2574-3805},

year  = {2023},

date = {2023-06-01},

journal = {JAMA network open},

volume = {6},

number = {6},

pages = {e2315578},

abstract = {IMPORTANCE: Several recent US Supreme Court rulings have drawn criticism from the medical community, but their health consequences have not been quantitatively evaluated. OBJECTIVE: To model health outcomes associated with 3 Supreme Court rulings in 2022 that invalidated workplace COVID-19 vaccine or mask-and-test requirements, voided state handgun-carry restrictions, and revoked the constitutional right to abortion. DESIGN, SETTING, AND PARTICIPANTS: This decision analytical modeling study estimated outcomes associated with 3 Supreme Court rulings in 2022: (1) National Federation of Independent Business v Department of Labor, Occupational Safety and Health Administration (OSHA), which invalidated COVID-19 workplace protections; (2) New York State Rifle and Pistol Association Inc v Bruen, Superintendent of New York State Police (Bruen), which voided state laws restricting handgun carry; and (3) Dobbs v Jackson Women's Health Organization (Dobbs), which revoked the constitutional right to abortion. Data analysis was performed from July 1, 2022, to April 7, 2023. MAIN OUTCOMES AND MEASURES: For the OSHA ruling, multiple data sources were used to calculate deaths attributable to COVID-19 among unvaccinated workers from January 4 to May 28, 2022, and the share of these deaths that would have been prevented by the voided protections. To model the Bruen decision, published estimates of the consequences of right-to-carry laws were applied to 2020 firearm-related deaths (and injuries) in 7 affected jurisdictions. For the Dobbs ruling, the model assessed unwanted pregnancy continuations, resulting from the change in distance to the closest abortion facility, and then excess deaths (and peripartum complications) from forcing these unwanted pregnancies to term. RESULTS: The decision model projected that the OSHA decision was associated with 1402 additional COVID-19 deaths (and 22 830 hospitalizations) in early 2022. In addition, the model projected that 152 additional firearm-related deaths (and 377 nonfatal injuries) annually will result from the Bruen decision. Finally, the model projected that 30 440 fewer abortions will occur annually due to current abortion bans stemming from Dobbs, with 76 612 fewer abortions if states at high risk for such bans also were to ban the procedure; these bans will be associated with an estimated 6 to 15 additional pregnancy-related deaths each year, respectively, and hundreds of additional cases of peripartum morbidity. CONCLUSIONS AND RELEVANCE: These findings suggest that outcomes from 3 Supreme Court decisions in 2022 could lead to substantial harms to public health, including nearly 3000 excess deaths (and possibly many more) over a decade.},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{gaffney_covid-19_2023,

title = {COVID-19 Risk by Workers' Occupation and Industry in the United States, 2020‒2021.},

author = {Adam Gaffney and David U. Himmelstein and Danny McCormick and Steffie Woolhandler},

doi = {10.2105/AJPH.2023.307249},

issn = {1541-0048 0090-0036},

year  = {2023},

date = {2023-06-01},

journal = {American journal of public health},

volume = {113},

number = {6},

pages = {647–656},

abstract = {Objectives. To assess the risk of COVID-19 by occupation and industry in the United States. Methods. Using the 2020-2021 National Health Interview Survey, we estimated the risk of having had a diagnosis of COVID-19 by workers' industry and occupation, with and without adjustment for confounders. We also examined COVID-19 period prevalence by the number of workers in a household. Results. Relative to workers in other industries and occupations, those in the industry "health care and social assistance" (adjusted prevalence ratio = 1.23; 95% confidence interval = 1.11, 1.37), or in the occupations "health practitioners and technical," "health care support," or "protective services" had elevated risks of COVID-19. However, compared with nonworkers, workers in 12 of 21 industries and 11 of 23 occupations (e.g., manufacturing, food preparation, and sales) were at elevated risk. COVID-19 prevalence rose with each additional worker in a household. Conclusions. Workers in several industries and occupations with public-facing roles and adults in households with multiple workers had elevated risk of COVID-19. Public Health Implications. Stronger workplace protections, paid sick leave, and better health care access might mitigate working families' risks from this and future pandemics. (Am J Public Health. 2023;113(6):647-656. https://doi.org/10.2105/AJPH.2023.307249).},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{gaffney_pulmonary_2023,

title = {Pulmonary Function Prediction Equations-Clinical Ramifications of a Universal Standard.},

author = {Adam Gaffney},

doi = {10.1001/jamanetworkopen.2023.16129},

issn = {2574-3805},

year  = {2023},

date = {2023-06-01},

journal = {JAMA network open},

volume = {6},

number = {6},

pages = {e2316129},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{gaffney_century-long_2023,

title = {Century-Long Trends in the Financing and Ownership of American Health Care.},

author = {Adam Gaffney and Steffie Woolhandler and David U. Himmelstein},

doi = {10.1111/1468-0009.12647},

issn = {1468-0009 0887-378X},

year  = {2023},

date = {2023-06-01},

journal = {The Milbank quarterly},

volume = {101},

number = {2},

pages = {325–348},

abstract = {Policy Points Over the past century, the tax-financed share of health care spending has risen from 9% in 1923 to 69% in 2020; a large part of this tax financing is now the subsidization of private health insurance. For-profit ownership of health care facilities has also increased in recent decades and now predominates for many health subsectors. A rising share of physicians are now employees. US health care is, increasingly, publicly financed yet investor owned, a trend that has been accompanied by rising medical costs and, in recent years, stagnating or even worsening population health. A reconsideration of US health care financing and ownership appears warranted. CONTEXT: Who pays for health care-and who owns it-determine what care is delivered, who receives it, and who profits from it. We examined trends in health care ownership and financing over a century. METHODS: We used multiple historical and current data sources (including data from the American Medical Association, the American Hospital Association, government publications and surveys, and analyses of Medicare Provider of Services files) to classify health care provider ownership as: public, private (for-profit), and private (not-for-profit). We used US Census data to classify physicians' employers as public, not-for-profit, or for-profit entities or "self-employed." We combined estimates from the official National Health Expenditures Accounts with other data sources to determine the public vs. private share of health care spending since 1923; we calculated a "comprehensive" public share metric that accounted for public subsidization of private health expenditures, mostly via the tax exemption for employer-sponsored insurance plans or government purchase of such plans for public employees. FINDINGS: For-profit ownership of most health care subsectors has risen in recent decades and now predominates in several (including nursing facilities, ambulatory surgical facilities, dialysis facilities, hospices, and home health agencies). However, most community hospitals remain not-for-profit. Additionally, over the past century, a growing share of physicians identify as employees. Meanwhile, the comprehensive taxpayer-financed share of health care spending has increased dramatically from 9% in 1923 to 69% in 2020, with taxpayer-financed subsidies to private expenditures accounting for much of the recent growth. CONCLUSIONS: American health care is increasingly publicly financed yet investor owned, a trend accompanied by rising costs and, recently, worsening population health. A reassessment of the US mode of health care financing and ownership appears warranted.},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{narm_chronic_2023,

title = {Chronic Illness in Children and Foregone Care Among Household Adults in the United States: A National Study.},

author = {Koh Eun Narm and Jenny Wen and Lily Sung and Sofia Dar and Paul Kim and Brady Olson and Alix Schrager and Annie Tsay and David U. Himmelstein and Steffie Woolhandler and Natalie Shure and Danny McCormick and Adam Gaffney},

doi = {10.1097/MLR.0000000000001791},

issn = {1537-1948 0025-7079},

year  = {2023},

date = {2023-04-01},

journal = {Medical care},

volume = {61},

number = {4},

pages = {185–191},

abstract = {BACKGROUND: Childhood chronic illness imposes financial burdens that may affect the entire family. OBJECTIVE: The aim was to assess whether adults living with children with 2 childhood chronic illnesses-asthma and diabetes-are more likely to forego their own medical care, and experience financial strain, relative to those living with children without these illnesses. RESEARCH DESIGN: 2009-2018 National Health Interview Survey. SUBJECTS: Adult-child dyads, consisting of one randomly sampled child and adult in each family. MEASURES: The main exposure was a diagnosis of asthma or diabetes in the child. The outcomes were delayed/foregone medical care for the adult as well as family financial strain; the authors evaluated their association with the child's illness using multivariable logistic regressions adjusted for potential confounders. RESULTS: The authors identified 93,264 adult-child dyads; 8499 included a child with asthma, and 179 a child with diabetes. Families with children with either illness had more medical bill problems, food insecurity, and medical expenses. Adults living with children with each illness reported more health care access problems. For instance, relative to other adults, those living with a child with asthma were more likely to forego/delay care (14.7% vs. 10.2%, adjusted odds ratio: 1.27; 95% CI: 1.16-1.39) and were more likely to forego medications, specialist, mental health, and dental care. Adults living with a child with diabetes were also more likely to forego/delay care (adjusted odds ratio: 1.76; 95% CI: 1.18-2.64). CONCLUSIONS: Adults living with children with chronic illnesses may sacrifice their own care because of cost concerns. Reducing out-of-pocket health care costs, improving health coverage, and expanding social supports for families with children with chronic conditions might mitigate such impacts.},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{gaffney_uptake_2023,

title = {Uptake and Equity in Influenza Vaccination Among Veterans with VA Coverage, Veterans Without VA Coverage, and Non-Veterans in the USA, 2019-2020.},

author = {Adam Gaffney and David U. Himmelstein and Samuel Dickman and Danny McCormick and Stephanie Woolhandler},

doi = {10.1007/s11606-022-07797-7},

issn = {1525-1497 0884-8734},

year  = {2023},

date = {2023-04-01},

journal = {Journal of general internal medicine},

volume = {38},

number = {5},

pages = {1152–1159},

abstract = {BACKGROUND: Vaccination is a primary method of reducing the burden of influenza, yet uptake is neither optimal nor equitable. Single-tier, primary care-oriented health systems may have an advantage in the efficiency and equity of vaccination. OBJECTIVE: To assess the association of Veterans' Health Administration (VA) coverage with influenza vaccine uptake and disparities. DESIGN: Cross-sectional. PARTICIPANTS: Adult respondents to the 2019-2020 National Health Interview Survey. MAIN MEASURES: We examined influenza vaccination rates, and racial/ethnic and income-based vaccination disparities, among veterans with VA coverage, veterans without VA coverage, and adult non-veterans. We performed multivariable logistic regressions adjusted for demographics and self-reported health, with interaction terms to examine differential effects by race/ethnicity and income. KEY RESULTS: Our sample included n=2,277 veterans with VA coverage},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{gaffney_trends_2023,

title = {Trends and Disparities in the Distribution of Outpatient Physicians' Annual Face Time with Patients, 1979-2018.},

author = {Adam Gaffney and David U. Himmelstein and Samuel Dickman and Danny McCormick and Christopher Cai and Steffie Woolhandler},

doi = {10.1007/s11606-022-07688-x},

issn = {1525-1497 0884-8734},

year  = {2023},

date = {2023-02-01},

journal = {Journal of general internal medicine},

volume = {38},

number = {2},

pages = {434–441},

abstract = {BACKGROUND: Physician time is a valuable yet finite resource. Whether such time is apportioned equitably among population subgroups, and how the provision of that time has changed in recent decades, is unclear. OBJECTIVE: To investigate trends and racial/ethnic disparities in the receipt of annual face time with physicians in the USA. DESIGN: Repeated cross-sectional. SETTING: National Ambulatory Medical Care Survey, 1979-1981, 1985, 1989-2016, 2018. PARTICIPANTS: Office-based physicians. MEASURES: Exposures included race/ethnicity (White, Black, and Hispanic); age (<18, 18-64, and 65+); and survey year. Our main outcome was patients' annual visit face time with a physician; secondary outcomes include annual visit rates and mean visit duration. RESULTS: Our sample included n=1,108,835 patient visits. From 1979 to 2018, annual outpatient physician face time per capita rose from 40.0 to 60.4 min, an increase driven by a rise in mean visit length and not in the number of visits. However, since 2005, mean annual face time with a primary care physician has fallen, a decline offset by rising time with specialists. Face time provided per physician changed little given growth in the physician workforce. A racial/ethnic gap in physician visit time present at the beginning of the study period widened over time. In 2014-2018, White individuals received 70.0 min of physician face time per year, vs. 52.4 among Black and 53.0 among Hispanic individuals. This disparity was driven by differences in visit rates, not mean visit length, and in the provision of specialist but not primary care. LIMITATION: Self-reported visit length. CONCLUSION: Americans' annual face time with office-based physicians rose for three decades after 1979, yet is still allocated inequitably, particularly by specialists; meanwhile, time spent by Americans with primary care physicians is falling. These trends and disparities may adversely affect patient outcomes. Policy change is needed to assure better allocation of this resource.},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{gaffney_community_2023,

title = {Community Health, Health Care Access, And COVID-19 Booster Uptake In Massachusetts.},

author = {Adam Gaffney and Steffie Woolhandler and Jacob Bor and Danny McCormick and David U. Himmelstein},

doi = {10.1377/hlthaff.2022.00835},

issn = {2694-233X 0278-2715},

year  = {2023},

date = {2023-02-01},

journal = {Health affairs (Project Hope)},

volume = {42},

number = {2},

pages = {268–276},

abstract = {Booster vaccination offers vital protection against COVID-19, particularly for communities in which many people have chronic conditions. Although vaccination has been widely and freely available, people who have experienced barriers to care might be deterred from being vaccinated. We examined the relationship between COVID-19 booster uptake and small area-level demographics, chronic disease prevalence, and measures of health care access in 462 Massachusetts communities during the period September 2021-April 2022. Unadjusted analyses found that booster uptake was higher in older and wealthier areas, lower in areas with more Hispanic and Black residents, and lower in areas with a high prevalence of chronic conditions. In both unadjusted and adjusted analyses, uptake was lower in communities with more uninsured residents and those in which fewer residents received routine medical check-ups. Adjusted analyses found that areas with more vaccine providers and primary care physicians had higher booster uptake, but this association was not significant in unadjusted analyses. Results suggest a need for innovative outreach efforts, as well as structural changes such as expansion of health care coverage and universal access to care to mitigate the inequitable burden of COVID-19.},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{himmelstein_specialty_2022,

title = {Specialty Care Utilization Among Adults with Limited English Proficiency.},

author = {Jessica Himmelstein and Christopher Cai and David U. Himmelstein and Steffie Woolhandler and David H. Bor and Samuel L. Dickman and Danny McCormick},

doi = {10.1007/s11606-022-07477-6},

issn = {1525-1497 0884-8734},

year  = {2022},

date = {2022-12-01},

journal = {Journal of general internal medicine},

volume = {37},

number = {16},

pages = {4130–4136},

abstract = {BACKGROUND: People with limited English proficiency (LEP) face greater barriers to accessing medical care than those who are English proficient (EP). Language-related differences in the use of outpatient care across the full spectrum of physician specialties have not been studied. OBJECTIVE: To compare outpatient visit rates to physicians in 28 specialties by people with LEP vs EP. DESIGN: Multivariable negative binomial regression analysis of nationally representative data from the Medical Expenditure Panel Survey (pooled 2013-2018) with adjustment for age, sex, and self-reported health status. PARTICIPANTS: 149,611 survey respondents aged 18 and older. EXPOSURE: LEP, defined as taking the survey in a language other than English. MAIN MEASURES: Annual per capita adjusted visit rate ratios (ARRs) comparing visit rates by LEP and EP persons to individual specialties, and to three categories of specialties: (1) primary care (internal or family medicine, geriatrics, general practice, or obstetrics/gynecology), (2) medical-subspecialties, or (3) surgical specialties. KEY RESULTS: Patients with LEP were underrepresented in 26 of 28 specialties. Disparities were particularly large for the following: pulmonology (ARR, 0.26; 95% CI, 0.20-0.35), orthopedics (ARR, 0.35; 95% CI, 0.30-0.40), otolaryngology (ARR, 0.40; 95% CI, 0.27-0.59), and psychiatry (ARR, 0.43; 95% CI, 0.32-0.58). Among individuals with several specific common chronic conditions, LEP-EP disparities in visits to specialties in those conditions generally persisted. Disparities were larger for medical subspecialties (ARR, 0.41; 95% CI, 0.36-0.46) and surgical specialties (ARR, 0.46; 95% CI, 0.42-0.50) than for primary care (ARR, 0.76; 95% CI, 0.72 to 0.79). CONCLUSIONS: Patients with LEP are underrepresented in most outpatient specialty practices, particularly medical subspecialties and surgical specialties. Our findings highlight the need to remove language barriers to physician services in order to ensure access to the full spectrum of outpatient specialty care for people with LEP.},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{white_association_2022,

title = {Association of Texas' 2021 Ban on Abortion in Early Pregnancy With the Number of Facility-Based Abortions in Texas and Surrounding States.},

author = {Kari White and Gracia Sierra and Klaira Lerma and Anitra Beasley and Lisa G. Hofler and Kristina Tocce and Vinita Goyal and Tony Ogburn and Joseph E. Potter and Samuel L. Dickman},

doi = {10.1001/jama.2022.20423},

issn = {1538-3598 0098-7484},

year  = {2022},

date = {2022-11-01},

journal = {JAMA},

volume = {328},

number = {20},

pages = {2048–2055},

abstract = {IMPORTANCE: Texas' 2021 ban on abortion in early pregnancy may demonstrate how patterns of abortion might change following the US Supreme Court's June 2022 decision overturning Roe v Wade. OBJECTIVE: To assess changes in the number of abortions and changes in the percentage of out-of-state abortions among Texas residents performed at 12 or more weeks of gestation in the first 6 months following implementation of Texas Senate Bill 8 (SB 8), which prohibited abortions after detection of embryonic cardiac activity. DESIGN, SETTING, AND PARTICIPANTS: Retrospective study of a sample of 50 Texas and out-of-state abortion facilities using an interrupted time series analysis to assess changes in the number of abortions, and Poisson regression to assess changes in abortions at 12 or more weeks of gestation. Data included 68 820 Texas facility-based abortions and 11 287 out-of-state abortions among Texas residents during the study period from September 1, 2020, to February 28, 2022. EXPOSURES: Abortion care obtained after (September 2021-February 2022) vs before (September 2020-August 2021) implementation of SB 8. MAIN OUTCOMES AND MEASURES: Primary outcomes were changes in the number of facility-based abortions for Texas residents, in Texas and out of state, in the month after implementation of SB 8 compared with the month before. The secondary outcome was the change in the percentage of out-of-state abortions among Texas residents obtained at 12 or more weeks of gestation during the 6-month period after the law's implementation. RESULTS: Between September 2020 and August 2021, there were 55 018 abortions in Texas and 2547 out-of-state abortions among Texas residents. During the 6 months after SB 8, there were 13 802 abortions in Texas and 8740 out-of-state abortions among Texas residents. Compared with the month before implementation of SB 8, the number of Texas facility-based abortions significantly decreased from 5451 to 2169 (difference, -3282 [95% CI, -3171 to -3396]; incidence rate ratio [IRR], 0.43 [95% CI, 0.36-0.51]) in the month after SB 8 was implemented. The number of out-of-state abortions among Texas residents significantly increased from 222 to 1332 (difference, 1110 [95% CI, 1047-1177]; IRR, 5.38 [95% CI, 4.19-6.91]). Overall, the total documented number of Texas facility-based and out-of-state abortions among Texas residents significantly decreased from 5673 to 3501 (absolute change, -2172 [95% CI, -2083 to -2265]; IRR, 0.67 [95% CI, 0.56-0.79]) in the first month after SB 8 was implemented compared with the previous month. Out-of-state abortions among Texas residents obtained at 12 or more weeks of gestation increased from 17.1% (221/1291) to 31.0% (399/1289) (difference, 178 [95% CI, 153-206]) during the period between September 2021 and February 2022 (P < .001 for trend). CONCLUSIONS AND RELEVANCE: Among a sample of abortion facilities, the 2021 Texas law banning abortion in early pregnancy (SB 8) was significantly associated with a decrease in the documented total of facility-based abortions in Texas and obtained by Texas residents in surrounding states in the first month after implementation compared with the previous month. Over the 6 months following SB 8 implementation, the percentage of out-of-state abortions among Texas residents obtained at 12 or more weeks of gestation significantly increased.},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{gaffney_disparities_2022,

title = {Disparities in Disease Burden and Treatment of Patients Asthma and Chronic Obstructive Pulmonary Disease.},

author = {Adam W. Gaffney},

doi = {10.1016/j.mcna.2022.08.005},

issn = {1557-9859 0025-7125},

year  = {2022},

date = {2022-11-01},

journal = {The Medical clinics of North America},

volume = {106},

number = {6},

pages = {1027–1039},

abstract = {Lung health reflects the inequities of our society. Asthma and chronic obstructive pulmonary disease are 2 lung conditions commonly treated in general clinical practice; each imposes a disproportionate burden on disadvantaged patients. Numerous factors mediate disparities in lung health, including air pollution, allergen exposures, tobacco, and respiratory infections. Members of racial/ethnic minorities and those of low socioeconomic status also have inferior access to high-quality medical care, compounding disparities in disease burden. Physicians can work against disparities in their practice, but wide-ranging policy reforms to achieve better air quality, housing, workplace safety, and healthcare for all are needed to achieve equity in lung health.},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{gaffney_prevalence_2022,

title = {Prevalence and Correlates of Patient Rationing of Insulin in the United States: A National Survey.},

author = {Adam Gaffney and David U. Himmelstein and Steffie Woolhandler},

doi = {10.7326/M22-2477},

issn = {1539-3704 0003-4819},

year  = {2022},

date = {2022-11-01},

journal = {Annals of internal medicine},

volume = {175},

number = {11},

pages = {1623–1626},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{ommerborn_assessment_2022,

title = {Assessment of Immigrants' Premium and Tax Payments for Health Care and the Costs of Their Care.},

author = {Mark J. Ommerborn and Lynsie R. Ranker and Sharon Touw and David U. Himmelstein and Jessica Himmelstein and Steffie Woolhandler},

doi = {10.1001/jamanetworkopen.2022.41166},

issn = {2574-3805},

year  = {2022},

date = {2022-11-01},

journal = {JAMA network open},

volume = {5},

number = {11},

pages = {e2241166},

abstract = {IMPORTANCE: Some worry that immigrants burden the US economy and particularly the health care system. However, no analyses to date have assessed whether immigrants' payments for premiums and taxes that fund health care programs exceed third-party payers' expenditures on their behalf. OBJECTIVE: To assess immigrants' net financial contributions to US health care programs. DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional analysis used 2017 data from the Medical Expenditure Panel Survey (MEPS) and the Current Population Survey (CPS) and 2014 to 2018 data from the American Community Survey. The main analyses used data from the calendar year 2017. Data from the calendar years 2012 to 2016 were also reported. Data were analyzed from June 15, 2020, to August 14, 2022. Participants comprised 210 669 community-dwelling respondents to the MEPS and CPS (main analysis) and nursing home residents who were included in the American Community Survey (additional analysis). EXPOSURES: Citizenship and immigration status. MAIN OUTCOMES AND MEASURES: Total and per capita payments for premiums and taxes that fund health care as well as third-party payers' expenditures for health care in 2018 US dollars. RESULTS: Among 210 669 participants, 51.0% were female, 18.3% were Hispanic, 12.3% were non-Hispanic Black, 60.3% were non-Hispanic White, and 9.2% were of other races and/or ethnicities. A total of 180 084 participants were respondents to the 2018 CPS, and 30 585 were respondents to the 2017 MEPS. Among the 180 084 CPS respondents, immigrants accounted for 14.1% (weighted to be nationally representative), with the subgroup of citizen immigrants accounting for 6.8%, documented noncitizen immigrants accounting for 3.7%, and undocumented immigrants accounting for 3.6%; US-born citizens constituted 85.9% of the population. Relative to US-born citizens, immigrants were more often age 18 to 64 years (79.6% vs 58.3%), of Hispanic ethnicity (45.0% vs 14.0%), and uninsured (16.8% vs 7.4%); similar percentages (51.4% vs 50.9%) were female. US-born citizens vs immigrants paid similar amounts in premiums and taxes ($6269 per capita [95% CI, $6185-$6353 per capita] vs $6345 per capita [95% CI, $6220-$6470 per capita]). However, third-party expenditures for immigrants' health care ($5061 per capita; 95% CI, $4673-$5448 per capita) were lower than their expenditures for the care of US-born citizens ($6511 per capita; 95% CI, $6275-$6747 per capita). Immigrants, in general, paid significantly more per person (net contribution, $1284; 95% CI, $876-$1691) than was paid on their behalf. Most of this surplus was accounted for by undocumented immigrants, whose contributions exceeded their expenditures by $4418 per person (95% CI, $4047-$4789 per person). US-born citizens collectively paid $67.2 billion (95% CI, -$2.3 to $136.3 billion) less in premiums and taxes than third-party payers paid for their care. This deficit was mostly offset by the $58.3 billion (95% CI, $39.8-$76.8 billion) net surplus of payments from immigrants, 89% of which ($51.9 billion; 95% CI, $47.5-$56.3 billion) was attributable to undocumented immigrants. CONCLUSIONS AND RELEVANCE: In this study, immigrants appeared to subsidize the health care of other US residents, suggesting that concerns that immigrants deplete health care resources may be unfounded.},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{cai_racial_2022,

title = {Racial and Ethnic Inequities in Diabetes Pharmacotherapy: Black and Hispanic Patients Are Less Likely to Receive SGLT2is and GLP1as.},

author = {Christopher Cai and Steffie Woolhandler and Danny McCormick and David U. Himmelstein and Jessica Himmelstein and Elizabeth Schrier and Samuel L. Dickman},

doi = {10.1007/s11606-022-07428-1},

issn = {1525-1497 0884-8734},

year  = {2022},

date = {2022-10-01},

journal = {Journal of general internal medicine},

volume = {37},

number = {13},

pages = {3501–3503},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{gao_primary_2022,

title = {Primary Care's Effects on Costs in the US Veterans Health Administration, 2016-2019: an Observational Cohort Study.},

author = {Jian Gao and Eileen Moran and Steffie Woolhandler and Andrew Toporek and Andrew P. Wilper and David U. Himmelstein},

doi = {10.1007/s11606-021-07140-6},

issn = {1525-1497 0884-8734},

year  = {2022},

date = {2022-10-01},

journal = {Journal of general internal medicine},

volume = {37},

number = {13},

pages = {3289–3294},

abstract = {BACKGROUND: Enhancing primary care is a promising strategy for improving the efficiency of health care. Previous studies of primary care's effects on health expenditures have mostly relied on ecological analyses comparing region-wide expenditures rather than spending for individual patients. OBJECTIVE: To compare overall medical expenditures for individual patients enrolled vs. those not enrolled in primary care in the Veterans Health Administration (VHA). DESIGN: Cohort study with stratification for clinical risk and multivariable linear regression models adjusted for clinical and demographic confounders of expenditures. PARTICIPANTS: In total, 6,009,973 VHA patients in fiscal year (FY) 2019-5,410,034 enrolled with a primary care provider (PCP) and 599,939 without a PCP-and similar numbers in FYs 2016-2018. MAIN MEASURES: Total annual cost per patient to the VHA (including VHA payments to non-VHA providers) stratified by a composite health risk score previously shown to predict VHA expenditures, and multivariate models additionally adjusted for VHA regional differences, patients' demographic characteristics, non-VHA insurance coverage, and driving time to the nearest VHA facility. Sensitivity analyses explored different modeling strategies and risk adjusters, as well as the inclusion of expenditures by the Medicare program that covers virtually all elderly VHA patients for care not paid for by the VHA. KEY RESULTS: Within each health-risk decile, non-PCP patients had higher outpatient, inpatient, and total costs than those with a PCP. After adjustment for health risk and other factors, lack of a PCP was associated 27.4% higher VHA expenditures, $3274 per patient annually (p < .0001). Sensitivity analyses using different risk adjusters and including Medicare's spending for VHA patients yielded similar results. CONCLUSIONS: In the VHA system, primary care is associated with substantial cost savings. Investments in primary care in other settings might also be cost-effective.},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{dickman_uncovered_2022,

title = {Uncovered Medical Bills after Sexual Assault.},

author = {Samuel L. Dickman and Gracie Himmelstein and David U. Himmelstein and Katherine Strandberg and Alecia McGregor and Danny McCormick and Steffie Woolhandler},

doi = {10.1056/NEJMc2207644},

issn = {1533-4406 0028-4793},

year  = {2022},

date = {2022-09-01},

journal = {The New England journal of medicine},

volume = {387},

number = {11},

pages = {1043–1044},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{himmelstein_prevalence_2022,

title = {Prevalence and Risk Factors for Medical Debt and Subsequent Changes in Social Determinants of Health in the US.},

author = {David U. Himmelstein and Samuel L. Dickman and Danny McCormick and David H. Bor and Adam Gaffney and Steffie Woolhandler},

doi = {10.1001/jamanetworkopen.2022.31898},

issn = {2574-3805},

year  = {2022},

date = {2022-09-01},

journal = {JAMA network open},

volume = {5},

number = {9},

pages = {e2231898},

abstract = {IMPORTANCE: Cost barriers discourage many US residents from seeking medical care and many who obtain it experience financial hardship. However, little is known about the association between medical debt and social determinants of health (SDOH). OBJECTIVE: To determine the prevalence of and risk factors associated with medical debt and the association of medical debt with subsequent changes in the key SDOH of food and housing security. DESIGN, SETTING, AND PARTICIPANTS: Cross-sectional analyses using multivariable logistic regression models controlled for demographic, financial, insurance, and health-related factors, and prospective cohort analyses assessing changes over time using the 2018, 2019, and 2020 Surveys of Income and Program Participation. Participants were nationally representative samples of US adults surveyed for 1 to 3 years. EXPOSURES: Insurance-related and health-related characteristics as risk factors for medical debt; Newly incurred medical debt as a risk factor for deterioration in SDOHs. MAIN OUTCOMES AND MEASURES: Prevalence and amounts of medical debt; 4 SDOHs: inability to pay rent or mortgage or utilities; eviction or foreclosure; and food insecurity. RESULTS: Among 51 872 adults surveyed regarding 2017, 40 784 regarding 2018 and 43 220 regarding 2019, 51.6% were female, 16.8% Hispanic, 6.0% were non-Hispanic Asian, 11.9% non-Hispanic Black, 62.6% non-Hispanic White, and 2.18% other non-Hispanic. A total of 10.8% (95% CI, 10.6-11.0) of individuals and approximately 18.1% of households carried medical debt. Persons with low and middle incomes had similar rates: 15.3%; (95% CI,14.4-16.2) of uninsured persons had debt, as did 10.5% (95% CI, 10.2-18.8) of the privately-insured. In 2018 the mean medical debt was $21 687/debtor (median $2000 [IQR, $597-$5000]). In cross-sectional analyses, hospitalization, disability, and having private high-deductible, Medicare Advantage, or no coverage were risk factors associated with medical indebtedness; residing in a Medicaid-expansion state was protective (2019 odds ratio [OR], 0.76; 95% CI, 0.70-0.83). Prospective findings were similar, eg, losing insurance coverage between 2017 and 2019 was associated with acquiring medical debt by 2019 (OR, 1.63; 95% CI, 1.23-2.14), as was becoming newly disabled (OR, 2.42; 95% CI, 1.95-3.00) or newly hospitalized (OR, 2.95; 95% CI, 2.40-3.62). Acquiring medical debt between 2017 and 2019 was a risk factor associated with worsening SDOHs, with ORs of 2.20 (95% CI,1.58-3.05) for becoming food insecure; 2.29 (95% CI, 1.73-3.03) for losing ability to pay rent or mortgage; 2.37 (95% CI, 1.75-3.23) for losing ability to pay utilities; and 2.95 (95% CI, 1.38-6.31) for eviction or foreclosure in 2019. CONCLUSIONS AND RELEVANCE: In this cross-sectional and cohort study, medical indebtedness was common, even among insured individuals. Acquiring such debt may worsen SDOHs. Expanded and improved health coverage could ameliorate financial distress, and improve housing and food security.},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{gaffney_disparities_2022-1,

title = {Disparities in COVID-19 Vaccine Booster Uptake in the USA: December 2021-February 2022.},

author = {Adam Gaffney and David U. Himmelstein and Danny McCormick and Steffie Woolhandler},

doi = {10.1007/s11606-022-07648-5},

issn = {1525-1497 0884-8734},

year  = {2022},

date = {2022-08-01},

journal = {Journal of general internal medicine},

volume = {37},

number = {11},

pages = {2918–2921},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{gaffney_reply_2022,

title = {Reply: Trends in Smoking Prevalence and the Continuing Imperative of Tobacco Control.},

author = {Adam Gaffney and David U. Himmelstein and Steffie Woolhandler},

doi = {10.1513/AnnalsATS.202204-354LE},

issn = {2325-6621 2329-6933},

year  = {2022},

date = {2022-08-01},

journal = {Annals of the American Thoracic Society},

volume = {19},

number = {8},

pages = {1441–1442},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{saluja_preventing_2022,

title = {Preventing Financial Strain for Low- and Moderate-Income Adults: a Comparison of Medicaid, Marketplace, and Employer-Sponsored Insurance.},

author = {Sonali Saluja and Cameron Kaplan and Pooja Dhupati and Danny McCormick},

doi = {10.1007/s11606-021-07100-0},

issn = {1525-1497 0884-8734},

year  = {2022},

date = {2022-08-01},

journal = {Journal of general internal medicine},

volume = {37},

number = {10},

pages = {2373–2381},

abstract = {BACKGROUND: Medicaid expansion and subsidized private plans purchased on the Affordable Care Act's (ACA) Marketplaces accounted for most of the ACA's coverage gains. OBJECTIVE: Compare access to care and financial strain between Medicaid and Marketplace plans, and benchmark these against employer-sponsored insurance (ESI) plans. DESIGN: Cross-sectional survey PARTICIPANTS: A nationally representative, non-institutionalized sample of 37,219 non-elderly adults with incomes up to 400% of the federal poverty level between 2015 and 2018, and a sub-group of individuals with chronic diseases. MAIN MEASURES: Self-reported barriers to accessing care, cost-related medication non-adherence, and financial strain. KEY RESULTS: Marketplace enrollees were more likely than Medicaid enrollees to delay or avoid care due to cost (19.3% vs 10.0%; adjusted difference (AD), 8.6 [95% CI, 6.8 to 10.4]) and report difficulties affording specialty care (7.7% vs 6.6%; AD, 1.8% [95% CI, 0.3% to 3.3%]), while there were no differences in having insurance accepted by a doctor or ability to afford dental care. Marketplace enrollees were also more likely to report cost-related medication non-adherence (21.5% vs 20.0%; AD, 4.0 [CI, 1.5 to 6.4]), be very worried about not being able to pay medical costs in case of a serious accident (32.3% vs 25.8%; AD, 6.4 [CI, 4.2 to 8.6]), have expenses exceeding $2000 (22.4% vs 5.4%; AD, 8.3 [CI, 6.2 to 10.3]), and have problems paying medical bills (18.4% vs 15.6%; AD, 1.8 [CI, 0.3 to 3.9]). Marketplace-Medicaid differences were larger among persons with a chronic disease. Individuals in ESI plans fared better for most, but not all, outcomes. CONCLUSION: Medicaid offers better protections than Marketplace plans on most measures of access and financial strain.},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{dickman_trends_2022,

title = {Trends in Health Care Use Among Black and White Persons in the US, 1963-2019.},

author = {Samuel L. Dickman and Adam Gaffney and Alecia McGregor and David U. Himmelstein and Danny McCormick and David H. Bor and Steffie Woolhandler},

doi = {10.1001/jamanetworkopen.2022.17383},

issn = {2574-3805},

year  = {2022},

date = {2022-06-01},

journal = {JAMA network open},

volume = {5},

number = {6},

pages = {e2217383},

abstract = {IMPORTANCE: In the US, Black people receive less health care than White people. Data on long-term trends in these disparities, which provide historical context for interpreting contemporary inequalities, are lacking. OBJECTIVE: To assess trends in Black-White disparities in health care use since 1963. DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study analyzed 29 US surveys conducted between 1963 and 2019 of noninstitutionalized Black and non-Hispanic White civilians. EXPOSURES: Self-reported race and ethnicity. MAIN OUTCOMES AND MEASURES: Annual per capita visit rates (for ambulatory, dental, and emergency department care), inpatient hospitalization rates, and total per capita medical expenditures. RESULTS: Data from 154 859 Black and 446 944 White (non-Hispanic) individuals surveyed from 1963 to 2019 were analyzed (316 503 [52.6%] female; mean [SD] age, 37.0 [23.3] years). Disparities narrowed in the 1970s in the wake of landmark civil rights legislation and the implementation of Medicare and Medicaid but subsequently widened. For instance, the White-Black gap in ambulatory care visits decreased from 1.2 (95% CI, 1.0-1.4) visits per year in 1963 to 0.8 (95% CI, 0.6-1.0) visits per year in the 1970s and then increased, reaching 3.2 (95% CI, 3.0-3.4) visits per year in 2014 to 2019. Even among privately insured adults aged 18 to 64 years, White individuals used far more ambulatory care (2.6 [95% CI, 2.4-2.8] more visits per year) than Black individuals in 2014 to 2019. Similarly, White peoples' overall health care use, measured in dollars per capita, exceeded that of Black people in every year. After narrowing from 1.96 in the 1960s to 1.26 in the 1970s, the White-Black expenditure ratio began widening in the 1980s, reaching 1.46 in the 1990s; it remained between 1.31 and 1.39 in subsequent periods. CONCLUSIONS AND RELEVANCE: This study's findings indicate that racial inequities in care have persisted for 6 decades and widened in recent years, suggesting the persistence and even fortification of structural racism in health care access. Reform efforts should include training more Black health care professionals, investments in Black-serving health facilities, and implementing universal health coverage that eliminates cost barriers.},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{rastas_association_2022,

title = {Association Between High Deductible Health Plans and Cost-Related Non-adherence to Medications Among Americans with Diabetes: an Observational Study.},

author = {Charlotte Rastas and Drew Bunker and Vikas Gampa and John Gaudet and Shirin Karimi and Ariel Majidi and Gaurab Basu and Adam Gaffney and Danny McCormick},

doi = {10.1007/s11606-021-06937-9},

issn = {1525-1497 0884-8734},

year  = {2022},

date = {2022-06-01},

journal = {Journal of general internal medicine},

volume = {37},

number = {8},

pages = {1910–1916},

abstract = {BACKGROUND: For people with diabetes, adherence to prescribed medications is essential. However, the rising prevalence of high-deductible health plans (HDHPs), and prices of diabetes medications such as insulin, could deter adherence. OBJECTIVE: To assess the impact of HDHP on cost-related medication non-adherence (CRN) among non-elderly adults with diabetes in the US. DESIGN: Repeated cross-sectional survey. SETTING: National Health Interview Survey, 2011-2018. PARTICIPANTS: A total of 7469 privately insured adults ages 18-64 with diabetes who were prescribed medications and enrolled in a HDHP or a traditional commercial health plan (TCP). MAIN MEASURES: Self-reported measures of CRN were compared between enrollees in HDHPs and TCPs overall and among the subset using insulin. Analyses were adjusted for demographic and clinical characteristics using multivariable linear regression models. KEY RESULTS: HDHP enrollees were more likely than TCP enrollees to not fill a prescription (13.4% vs 9.9%; adjusted percentage point difference (AD) 3.4 [95% CI 1.5 to 5.4]); skip medication doses (11.4% vs 8.5%; AD 2.8 [CI 1.0 to 4.7]); take less medication (11.1% vs 8.8%; AD 2.3 [CI 0.5 to 4.0]); delay filling a prescription to save money (14.4% vs 10.8%; AD 3.0 [CI 1.1 to 4.9]); and to have any form of CRN (20.4% vs 15.5%; AD 4.4 [CI 2.2 to 6.7]). Among those taking insulin, HDHP enrollees were more likely to have any CRN (25.1% vs 18.9%; AD 5.9 [CI 1.1 to 10.8]). CONCLUSION: HDHPs are associated with greater CRN among people with diabetes, particularly those prescribed insulin. For people with diabetes, enrollment in non-HDHPs might reduce CRN to prescribed medications.},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{dickman_financial_2022,

title = {Financial Hardships Caused by Out-of-Pocket Abortion Costs in Texas, 2018.},

author = {Samuel L. Dickman and Kari White and Gracia Sierra and Daniel Grossman},

doi = {10.2105/AJPH.2021.306701},

issn = {1541-0048 0090-0036},

year  = {2022},

date = {2022-05-01},

journal = {American journal of public health},

volume = {112},

number = {5},

pages = {758–761},

abstract = {Objectives. To identify financial hardships related to costs of obtaining abortion care in Texas, which has the highest uninsured rate in the United States and restricts insurance coverage for abortions. Methods. We surveyed patients seeking abortion at 12 Texas clinics in 2018 regarding costs and financial hardships related to abortion care. We compared mean out-of-pocket costs and the percentage reporting hardships across income and insurance categories. Results. Of 603 respondents, 42% were Latinx, 25% White, and 21% Black or African American, and most (62.0%) reported having low incomes (< 200% federal poverty level). Mean out-of-pocket costs were $634, which varied little across insurance groups. Patients with low incomes were more likely to obtain financial assistance from an abortion fund than were wealthier patients (12.3% vs 1.6%, respectively; P < .05). Financial hardships related to abortion costs were more common among uninsured (57.6%) and publicly insured (55.1%) patients than those with private insurance (48.2%). One in 5 (19.8%) uninsured respondents delayed buying food to pay for abortion care. Conclusions. Restrictions on insurance coverage for abortions result in high out-of-pocket costs and major financial hardships for most patients with low incomes in Texas. (Am J Public Health. 2022;112(5):758-761. https://doi.org/10.2105/AJPH.2021.306701).},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{gaffney_intensive_2022,

title = {Intensive Care Unit Equity and Regionalization in the COVID-19 Era.},

author = {Adam W. Gaffney},

doi = {10.1513/AnnalsATS.202110-1200VP},

issn = {2325-6621 2329-6933},

year  = {2022},

date = {2022-05-01},

journal = {Annals of the American Thoracic Society},

volume = {19},

number = {5},

pages = {717–719},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{gaffney_medical_2022-1,

title = {Medical Documentation Burden Among US Office-Based Physicians in 2019: A National Study.},

author = {Adam Gaffney and Stephanie Woolhandler and Christopher Cai and David Bor and Jessica Himmelstein and Danny McCormick and David U. Himmelstein},

doi = {10.1001/jamainternmed.2022.0372},

issn = {2168-6114 2168-6106},

year  = {2022},

date = {2022-05-01},

journal = {JAMA internal medicine},

volume = {182},

number = {5},

pages = {564–566},

abstract = {This cross-sectional study uses data from the 2019 National Electronic Health Records Survey to assess the burden and time spent on medical documentation outside office hours among US physicians.},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{gaffney_covid-19_2022,

title = {COVID-19 Testing and Incidence Among Uninsured and Insured Individuals in 2020: a National Study.},

author = {Adam Gaffney and Steffie Woolhandler and David U. Himmelstein},

doi = {10.1007/s11606-022-07429-0},

issn = {1525-1497 0884-8734},

year  = {2022},

date = {2022-04-01},

journal = {Journal of general internal medicine},

volume = {37},

number = {5},

pages = {1344–1347},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{greep_physician_2022,

title = {Physician Burnout: Fix the Doctor or Fix the System?},

author = {Nancy C. Greep and Steffie Woolhandler and David Himmelstein},

doi = {10.1016/j.amjmed.2021.10.011},

issn = {1555-7162 0002-9343},

year  = {2022},

date = {2022-04-01},

journal = {The American journal of medicine},

volume = {135},

number = {4},

pages = {416–417},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{banerjee_readmissions_2022,

title = {Readmissions performance and penalty experience of safety-net hospitals under Medicare's Hospital Readmissions Reduction Program.},

author = {Souvik Banerjee and Michael K. Paasche-Orlow and Danny McCormick and Meng-Yun Lin and Amresh D. Hanchate},

doi = {10.1186/s12913-022-07741-9},

issn = {1472-6963},

year  = {2022},

date = {2022-03-01},

journal = {BMC health services research},

volume = {22},

number = {1},

pages = {338},

abstract = {BACKGROUND: The Hospital Readmissions Reduction Program (HRRP), established by the Centers for Medicare and Medicaid Services (CMS) in March 2010, introduced payment-reduction penalties on acute care hospitals with higher-than-expected readmission rates for acute myocardial infarction (AMI), heart failure, and pneumonia. There is concern that hospitals serving large numbers of low-income and uninsured patients (safety-net hospitals) are at greater risk of higher readmissions and penalties, often due to factors that are likely outside the hospital's control. Using publicly reported data, we compared the readmissions performance and penalty experience among safety-net and non-safety-net hospitals. METHODS: We used nationwide hospital level data for 2009-2016 from the Centers for Medicare and Medicaid Services (CMS) Hospital Compare program, CMS Final Impact Rule, and the American Hospital Association Annual Survey. We identified as safety-net hospitals the top quartile of hospitals in terms of the proportion of patients receiving income-based public benefits. Using a quasi-experimental difference-in-differences approach based on the comparison of pre- vs. post-HRRP changes in (risk-adjusted) 30-day readmission rate in safety-net and non-safety-net hospitals, we estimated the change in readmissions rate associated with HRRP. We also compared the penalty frequency among safety-net and non-safety-net hospitals. RESULTS: Our study cohort included 1915 hospitals, of which 479 were safety-net hospitals. At baseline (2009), safety-net hospitals had a slightly higher readmission rate compared to non-safety net hospitals for all three conditions: AMI, 20.3% vs. 19.8% (p value< 0.001); heart failure, 25.2% vs. 24.2% (p-value< 0.001); pneumonia, 18.7% vs. 18.1% (p-value< 0.001). Beginning in 2012, readmission rates declined similarly in both hospital groups for all three cohorts. Based on difference-in-differences analysis, HRRP was associated with similar change in the readmissions rate in safety-net and non-safety-net hospitals for AMI and heart failure. For the pneumonia cohort, we found a larger reduction (0.23%; p < 0.001) in safety-net hospitals. The frequency of readmissions penalty was higher among safety-net hospitals. The proportion of hospitals penalized during all four post-HRRP years was 72% among safety-net and 59% among non-safety-net hospitals. CONCLUSIONS: Our results lend support to the concerns of disproportionately higher risk of performance-based penalty on safety-net hospitals.},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{gaffney_association_2022,

title = {Association of Uninsurance and VA Coverage with the Uptake and Equity of COVID-19 Vaccination: January-March 2021.},

author = {Adam W. Gaffney and Steffie Woolhandler and David U. Himmelstein},

doi = {10.1007/s11606-021-07332-0},

issn = {1525-1497 0884-8734},

year  = {2022},

date = {2022-03-01},

journal = {Journal of general internal medicine},

volume = {37},

number = {4},

pages = {1008–1011},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{gaffney_inequity_2022,

title = {Inequity and the Interstitium: Pushing Back on Disparities in Fibrosing Lung Disease in the United States and Canada.},

author = {Adam W. Gaffney and Anna J. Podolanczuk},

doi = {10.1164/rccm.202111-2652ED},

issn = {1535-4970 1073-449X},

year  = {2022},

date = {2022-02-01},

journal = {American journal of respiratory and critical care medicine},

volume = {205},

number = {4},

pages = {385–387},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{emery_preparing_2022,

title = {Preparing Doctors in Training for Health Activist Roles: A Cross-Institutional Community Organizing Workshop for Incoming Medical Residents.},

author = {Eleanor H. Emery and Jonathan D. Shaffer and Danny McCormick and Jessica Zeidman and Sophia R. Geffen and Predrag Stojicic and Marshall Ganz and Gaurab Basu},

doi = {10.15766/mep_2374-8265.11208},

issn = {2374-8265},

year  = {2022},

date = {2022-01-01},

journal = {MedEdPORTAL : the journal of teaching and learning resources},

volume = {18},

pages = {11208},

abstract = {INTRODUCTION: Physicians are increasingly being called on to address inequities created by social and structural determinants of health, yet few receive training in specific leadership skills that allow them to do so effectively. METHODS: We developed a workshop to introduce incoming medical interns from all specialties at Boston-area residency programs to community organizing as a framework for effective physician advocacy. We utilized didactic sessions, video examples, and small-group practice led by trained coaches to familiarize participants with one community organizing leadership skill-public narrative-as a means of creating the relationships that underlie collective action. We offered this 3-hour, cross-institutional workshop just prior to intern orientation and evaluated it through a postworkshop survey. RESULTS: In June 2019, 51 residents from 13 programs at seven academic medical centers attended this workshop. In the postworkshop survey, participants agreed with positive evaluative statements about the workshop's value and impact on their knowledge, with a mean score on all items of over 4 (5-point Likert scale},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{gaffney_health_2022,

title = {Health Care Disparities Across the Urban-Rural Divide: A National Study of Individuals with COPD.},

author = {Adam W. Gaffney and Laura Hawks and Alexander C. White and Steffie Woolhandler and David Himmelstein and David C. Christiani and Danny McCormick},

doi = {10.1111/jrh.12525},

issn = {1748-0361 0890-765X},

year  = {2022},

date = {2022-01-01},

journal = {The Journal of rural health : official journal of the American Rural Health Association and the National Rural Health Care Association},

volume = {38},

number = {1},

pages = {207–216},

abstract = {PURPOSE: The burden of chronic obstructive pulmonary disease (COPD) is high in rural America. Few studies, however, have examined urban/rural differences in health care access, or racial/ethnic and income disparities stratified by urban/rural residence, among persons with COPD. METHODS: We studied individuals age ≥ 40 years with COPD from the 2018 Behavioral Risk Factor Surveillance System. The primary exposure was "urban" or "rural" county of residence. We examined multiple health and health care access/services outcomes using logistic regressions adjusted for age and sex, and performed analyses stratified by rural/urban county that included additional adjustment for race/ethnicity or income. FINDINGS: Our sample included 34,439 individuals. COPD prevalence was 8.6% in rural counties versus 5.4% in urban counties. Rural residents with COPD were poorer, had less education, worse health, and more disability. Of the rural population with COPD, 12.6% were uninsured, versus 10.4% in urban areas (AOR 1.26; 95% CI: 1.00-1.58). Rural residents with COPD were more likely to have not seen a doctor due to cost (AOR 1.18; 95% CI: 1.02-1.36). Differences in other outcomes were mostly nonsignificant. We observed large access disparities by race/ethnicity and income among individuals in both urban and rural counties, with the highest rates of forgone care among minorities in rural counties. CONCLUSION: Patients with COPD in rural areas experience greater morbidity and obstacles to care than those in urban areas. Racial/ethnic minorities and those with low incomes-particularly in rural areas-are also at greater risk of forgoing doctor visits due to cost. Expanded access to health care could address respiratory health inequities.},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{himmelstein_covid-19-related_2022,

title = {COVID-19-Related Care for Hispanic Elderly Adults With Limited English Proficiency.},

author = {Jessica Himmelstein and David U. Himmelstein and Steffie Woolhandler and Samuel Dickman and Chris Cai and Danny McCormick},

doi = {10.7326/M21-2900},

issn = {1539-3704 0003-4819},

year  = {2022},

date = {2022-01-01},

journal = {Annals of internal medicine},

volume = {175},

number = {1},

pages = {143–145},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{gaffney_medical_2021,

title = {Medical Uninsurance and Underinsurance Among US Children: Findings From the National Survey of Children's Health, 2016-2019.},

author = {Adam Gaffney and Samuel Dickman and Christopher Cai and Danny McCormick and David U. Himmelstein and Steffie Woolhandler},

doi = {10.1001/jamapediatrics.2021.2822},

issn = {2168-6211 2168-6203},

year  = {2021},

date = {2021-12-01},

journal = {JAMA pediatrics},

volume = {175},

number = {12},

pages = {1279–1281},

abstract = {This cross-sectional study uses data from the 2016 to 2019 National Survey of Children’s Health to examine trends in both medical uninsurnace and underinsurance among US children.},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{gaffney_trends_2021,

title = {Trends and Disparities in Teleworking During the COVID-19 Pandemic in the USA: May 2020-February 2021.},

author = {Adam W. Gaffney and David U. Himmelstein and Steffie Woolhandler},

doi = {10.1007/s11606-021-07078-9},

issn = {1525-1497 0884-8734},

year  = {2021},

date = {2021-11-01},

journal = {Journal of general internal medicine},

volume = {36},

number = {11},

pages = {3647–3649},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{cai_racial_2021,

title = {Racial and Ethnic Disparities in Outpatient Visit Rates Across 29 Specialties.},

author = {Christopher Cai and Adam Gaffney and Alecia McGregor and Steffie Woolhandler and David U. Himmelstein and Danny McCormick and Samuel L. Dickman},

doi = {10.1001/jamainternmed.2021.3771},

issn = {2168-6114 2168-6106},

year  = {2021},

date = {2021-11-01},

journal = {JAMA internal medicine},

volume = {181},

number = {11},

pages = {1525–1527},

abstract = {This cross-sectional study examines US racial/ethnic disparities in outpatient visit rates to 29 physician specialties.},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{hawks_hawks_2021,

title = {Hawks et al. Respond.},

author = {Laura Hawks and Emily A. Wang and Benjamin Howell and Steffie Woolhandler and David U. Himmelstein and David Bor and Danny McCormick},

doi = {10.2105/AJPH.2021.306496},

issn = {1541-0048 0090-0036},

year  = {2021},

date = {2021-11-01},

journal = {American journal of public health},

volume = {111},

number = {11},

pages = {e2},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{gaffney_prognostic_2021,

title = {Prognostic implications of differences in forced vital capacity in black and white US adults: Findings from NHANES III with long-term mortality follow-up.},

author = {Adam W. Gaffney and Danny McCormick and Steffie Woolhandler and David C. Christiani and David U. Himmelstein},

doi = {10.1016/j.eclinm.2021.101073},

issn = {2589-5370},

year  = {2021},

date = {2021-09-01},

journal = {EClinicalMedicine},

volume = {39},

pages = {101073},

abstract = {BACKGROUND: Because Forced Vital Capacity (FVC) is reduced in Black relative to White Americans of the same age, sex, and height, standard lung function prediction equations assign a lower "normal" range for Black patients. The prognostic implications of this race correction are uncertain. METHODS: We analyzed 5,294 White and 3,743 Black participants age 20-80 in NHANES III, a nationally-representative US survey conducted 1988-94, which we linked to the National Death Index to assess mortality through December 31, 2015. We calculated the FVC-percent predicted among Black and White participants, first applying NHANES III White prediction equations to all persons, and then using standard race-specific prediction equations. We used Cox proportional hazard models to calculate the association between race and all-cause mortality without and with adjustment for FVC (using each FVC metric), smoking, socioeconomic factors, and comorbidities. FINDINGS: Black participants' age- and sex-adjusted mortality was greater than White participants (HR 1.46; 95%CI:1.29, 1.65). With adjustment for FVC in liters (mean 3.7 L for Black participants, 4.3 L for White participants) or FVC percent-predicted using White equations for everyone, Black race was no longer independently predictive of higher mortality (HR∼1.0). When FVC-percent predicted was "corrected" for race, Black individuals again showed increased mortality hazard. Deaths attributed to chronic respiratory disease were infrequent for both Black and White individuals. INTERPRETATION: Lower FVC in Black people is associated with elevated risk of all-cause mortality, challenging the standard assumption about race-based normal limits. Black-White disparities in FVC may reflect deleterious social/environmental exposures, not innate differences. FUNDING: No funding.},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{dickman_affordability_2021,

title = {Affordability and Access to Abortion Care in the United States.},

author = {Samuel L. Dickman and Kari White and Daniel Grossman},

doi = {10.1001/jamainternmed.2021.3502},

issn = {2168-6114 2168-6106},

year  = {2021},

date = {2021-09-01},

journal = {JAMA internal medicine},

volume = {181},

number = {9},

pages = {1157–1158},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{himmelstein_health_2021,

title = {Health Care Spending And Use Among Hispanic Adults With And Without Limited English Proficiency, 1999-2018.},

author = {Jessica Himmelstein and David U. Himmelstein and Steffie Woolhandler and David H. Bor and Adam Gaffney and Leah Zallman and Samuel Dickman and Danny McCormick},

doi = {10.1377/hlthaff.2020.02510},

issn = {2694-233X 0278-2715},

year  = {2021},

date = {2021-07-01},

journal = {Health affairs (Project Hope)},

volume = {40},

number = {7},

pages = {1126–1134},

abstract = {One in seven people in the US speak Spanish at home, and twenty-five million people in the US have limited English proficiency. Using nationally representative data from the Medical Expenditure Panel Survey, we compare health care spending for and health care use by Hispanics adults with limited English proficiency with spending for and use by English-proficient Hispanic and non-Hispanic adults. During 2014-18 mean annual per capita expenditures were $1,463 (35 percent) lower for Hispanic adults with limited English proficiency than for Hispanic adults who were English proficient, after adjustment for respondents' characteristics. Hispanic adults with limited English proficiency also made fewer outpatient and emergency department visits, had fewer inpatient days, and received fewer prescription medications than Hispanic adults who were English proficient. Health care spending gaps between Hispanic adults with limited English proficiency and non-Hispanic adults with English proficiency widened between 1999 and 2018. These language-based gaps in spending and use raise concern that language barriers may be obstructing access to care, resulting in underuse of medical services by adults with limited English proficiency.},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{dickman_mortality_2021,

title = {Mortality at For-Profit Versus Not-For-Profit Hemodialysis Centers: A Systematic Review and Meta-analysis.},

author = {Samuel Dickman and Reza Mirza and Maryam Kandi and Michael A. Incze and Lorin Dodbiba and Raad Yameen and Arnav Agarwal and Ying Zhang and Rakhshan Kamran and Rachel Couban and Gordon Guyatt and Steven Hanna},

doi = {10.1177/0020731420980682},

issn = {1541-4469 0020-7314},

year  = {2021},

date = {2021-07-01},

journal = {International journal of health services : planning, administration, evaluation},

volume = {51},

number = {3},

pages = {371–378},

abstract = {We conducted a systematic review and meta-analysis to assess differences in risk-adjusted mortality rates between for-profit (FP) and not-for-profit (NFP) hemodialysis facilities. We searched 10 databases for studies published between January 2001 to December 2019 that compared mortality at private hemodialysis facilities. We included observational studies directly comparing adjusted mortality rates between FP and NFP private hemodialysis providers in any language or country. We excluded evaluations of dialysis facilities that changed their profit status, studies with overlapping data, and studies that failed to adjust for patient age and some measure of clinical severity. Pairs of reviewers independently screened all titles and abstracts and the full text of potentially eligible studies, abstracted data, and assessed risk of bias, resolving disagreement by discussion. We included nine observational studies of hemodialysis facilities representing 1,163,144 patient-years. In pooled random-effects meta-analysis, the odds ratio of mortality in FP relative to NFP facilities was 1.07 (95% CI 1.04-1.11). Patients at FP hemodialysis facilities have 7 percent greater odds of death annually than patients with similar risk profiles at NFP facilities. Approximately 3,800 excess deaths might be averted annually if U.S. FP hemodialysis operators matched NFP mortality rates.},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{touw_immigrant_2021,

title = {Immigrant Essential Workers Likely Avoided Medicaid And SNAP Because Of A Change To The Public Charge Rule.},

author = {Sharon Touw and Grace McCormack and David U. Himmelstein and Steffie Woolhandler and Leah Zallman},

doi = {10.1377/hlthaff.2021.00059},

issn = {2694-233X 0278-2715},

year  = {2021},

date = {2021-07-01},

journal = {Health affairs (Project Hope)},

volume = {40},

number = {7},

pages = {1090–1098},

abstract = {During the COVID-19 pandemic in the US, essential workers have provided health care, food, and other necessities, often incurring considerable risk. At the pandemic's start, the federal government was in the process of tightening the "public charge" rule by adding nutrition and health benefits to the cash benefits that, if drawn, could subject immigrants to sanctions (for example, green card denial). Census Bureau data indicate that immigrants accounted for 13.6 percent of the population but 17.8 percent of essential workers in 2019. About 20.0 million immigrants held essential jobs, and more than one-third of these immigrants resided in US states bordering Mexico. Nationwide, 12.3 million essential workers and 18.9 million of their household members were at risk because of the new sanctions. The rule change (which was subsequently revoked) likely caused 2.1 million essential workers and household members to forgo Medicaid and 1.3 million to forgo Supplemental Nutrition Assistance Program assistance on the eve of the pandemic, highlighting the potential of immigration policy changes to exacerbate health risks.},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{gaffney_socioeconomic_2021,

title = {Socioeconomic Inequality in Respiratory Health in the US From 1959 to 2018.},

author = {Adam W. Gaffney and David U. Himmelstein and David C. Christiani and Steffie Woolhandler},

doi = {10.1001/jamainternmed.2021.2441},

issn = {2168-6114 2168-6106},

year  = {2021},

date = {2021-07-01},

journal = {JAMA internal medicine},

volume = {181},

number = {7},

pages = {968–976},

abstract = {IMPORTANCE: Air quality has improved and smoking rates have declined over the past half-century in the US. It is unknown whether such secular improvements, and other policies, have helped close socioeconomic gaps in respiratory health. OBJECTIVE: To describe long-term trends in socioeconomic disparities in respiratory disease prevalence, pulmonary symptoms, and pulmonary function. DESIGN, SETTING, AND PARTICIPANTS: This repeated cross-sectional analysis of the nationally representative National Health and Nutrition Examination Surveys (NHANES) and predecessor surveys, conducted from 1959 to 2018. included 160 495 participants aged 6 to 74 years. EXPOSURES: Family income quintile defined using year-specific thresholds; educational attainment. MAIN OUTCOMES AND MEASURES: Trends in socioeconomic disparities in prevalence of current/former smoking among adults aged 25 to 74 years; 3 respiratory symptoms (dyspnea on exertion, cough, and wheezing) among adults aged 40 to 74 years; asthma stratified by age (6-11, 12-17, and 18-74 years); chronic obstructive pulmonary disease ([COPD] adults aged 40-74 years); and 3 measures of pulmonary function (forced expiratory volume in 1 second [FEV1], forced vital capacity [FVC], and FEV1/FVC<0.70) among adults aged 24 to 74 years. RESULTS: Our sample included 160 495 individuals surveyed between 1959 and 2018: 27 948 children aged 6 to 11 years; 26 956 children aged 12 to 17 years; and 105 591 adults aged 18 to 74 years. Income- and education-based disparities in smoking prevalence widened from 1971 to 2018. Socioeconomic disparities in respiratory symptoms persisted or worsened from 1959 to 2018. For instance, from 1971 to 1975, 44.5% of those in the lowest income quintile reported dyspnea on exertion vs 26.4% of those in the highest quintile, whereas from 2017 to 2018 the corresponding proportions were 48.3% and 27.9%. Disparities in cough and wheezing rose over time. Asthma prevalence rose for all children after 1980, but more sharply among poorer children. Income-based disparities in diagnosed COPD also widened over time, from 4.5 percentage points (age- and sex-adjusted) in 1971 to 11.3 percentage points from 2013 to 2018. Socioeconomic disparities in FEV1 and FVC also increased. For instance, from 1971 to 1975, the age- and height-adjusted FEV1 of men in the lowest income quintile was 203.6 mL lower than men in the highest quintile, a difference that widened to 248.5 mL from 2007 to 2012 (95% CI, -328.0 to -169.0). However, disparities in rates of FEV1/FVC lower than 0.70 changed little. CONCLUSIONS AND RELEVANCE: Socioeconomic disparities in pulmonary health persisted and potentially worsened over the past 6 decades, suggesting that the benefits of improved air quality and smoking reductions have not been equally distributed. Socioeconomic position may function as an independent determinant of pulmonary health.},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{gaffney_national_2021,

title = {National Trends and Disparities in Health Care Access and Coverage Among Adults With Asthma and COPD: 1997-2018.},

author = {Adam W. Gaffney and Laura Hawks and David Bor and Alexander C. White and Steffie Woolhandler and Danny McCormick and David U. Himmelstein},

doi = {10.1016/j.chest.2021.01.035},

issn = {1931-3543 0012-3692},

year  = {2021},

date = {2021-06-01},

journal = {Chest},

volume = {159},

number = {6},

pages = {2173–2182},

abstract = {BACKGROUND: Racial and ethnic as well as economic disparities in access to care among persons with asthma and COPD have been described, but long-term access trends are unclear. RESEARCH QUESTION: Have health coverage and access to care and medications among adults with airways disease improved, and have disparities narrowed? STUDY DESIGN AND METHODS: Using the 1997 through 2018 National Health Interview Survey, we examined time trends in health coverage and the affordability of medical care and prescription drugs for adults with asthma and COPD, overall and by income and by race and ethnicity. We performed multivariate linear probability regressions comparing coverage and access in 2018 with that in 1997. RESULTS: Our sample included 76,843 adults with asthma and 30,548 adults with COPD. Among adults with asthma, lack of insurance rose in the first decade of the twenty-first century, peaking with the Great Recession, but fell after implementation of the Affordable Care Act (ACA). From 1997 through 2018, the uninsured rate among adults with asthma decreased from 19.4% to 9.6% (adjusted 9.27 percentage points; 95% CI, 7.1%-11.5%). However, the proportions delaying or foregoing medical care because of cost or going without medications did not improve. Racial and ethnic as well as economic disparities present in 1997 persisted over the study period. Trends and disparities among those with COPD were similar, although the proportion going without needed medications worsened, rising by an adjusted 7.8 percentage points. INTERPRETATION: Coverage losses among persons with airways disease in the first decade of the twenty-first century were reversed by the ACA, but neither care affordability nor disparities improved. Further reform is needed to close these gaps.},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{cai_trends_2021,

title = {Trends in Anxiety and Depression Symptoms During the COVID-19 Pandemic: Results from the US Census Bureau's Household Pulse Survey.},

author = {Christopher Cai and Steffie Woolhandler and David U. Himmelstein and Adam Gaffney},

doi = {10.1007/s11606-021-06759-9},

issn = {1525-1497 0884-8734},

year  = {2021},

date = {2021-06-01},

journal = {Journal of general internal medicine},

volume = {36},

number = {6},

pages = {1841–1843},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{gaffney_health_2021,

title = {Health Needs and Functional Disability Among Mail-Order Pharmacy Users in the US.},

author = {Adam W. Gaffney and Steffie Woolhandler and David Himmelstein},

doi = {10.1001/jamainternmed.2020.7254},

issn = {2168-6114 2168-6106},

year  = {2021},

date = {2021-04-01},

journal = {JAMA internal medicine},

volume = {181},

number = {4},

pages = {554–556},

abstract = {This cross-sectional study examines the health characteristics of individuals who use mail-order pharmacies.},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{banerjee_association_2021,

title = {Association between Medicare's Hospital Readmission Reduction Program and readmission rates across hospitals by medicare bed share.},

author = {Souvik Banerjee and Michael K. Paasche-Orlow and Danny McCormick and Meng-Yun Lin and Amresh D. Hanchate},

doi = {10.1186/s12913-021-06253-2},

issn = {1472-6963},

year  = {2021},

date = {2021-03-01},

journal = {BMC health services research},

volume = {21},

number = {1},

pages = {248},

abstract = {BACKGROUND: Medicare's Hospital Readmissions Reduction Program (HRRP), implemented beginning in 2013, seeks to incentivize Inpatient Prospective Payment System (IPPS) hospitals to reduce 30-day readmissions for selected inpatient cohorts including acute myocardial infarction, heart failure, and pneumonia. Performance-based penalties, which take the form of a percentage reduction in Medicare reimbursement for all inpatient care services, have a risk of unintended financial burden on hospitals that care for a larger proportion of Medicare patients. To examine the role of this unintended risk on 30-day readmissions, we estimated the association between the extent of their Medicare share of total hospital bed days and changes in 30-day readmissions. METHODS: We used publicly available nationwide hospital level data for 2009-2016 from the Centers for Medicare and Medicaid Services (CMS) Hospital Compare program, CMS Final Impact Rule, and the American Hospital Association Annual Survey. Using a quasi-experimental difference-in-differences approach, we compared pre- vs. post-HRRP changes in 30-day readmission rate in hospitals with high and moderate Medicare share of total hospital bed days ("Medicare bed share") vs. low Medicare bed share hospitals. RESULTS: We grouped the 1904 study hospitals into tertiles (low, moderate and high) by Medicare bed share; the average bed share in the three tertile groups was 31.2, 47.8 and 59.9%, respectively. Compared to low Medicare bed share hospitals, high bed share hospitals were more likely to be non-profit, have smaller bed size and less likely to be a teaching hospital. High bed share hospitals were more likely to be in rural and non-large-urban areas, have fewer lower income patients and have a less complex patient case-mix profile. At baseline, the average readmissions rate in the low Medicare bed share (control) hospitals was 20.0% (AMI), 24.7% (HF) and 18.4% (pneumonia). The observed pre- to post-program change in the control hospitals was - 1.35% (AMI), - 1.02% (HF) and - 0.35% (pneumonia). Difference in differences model estimates indicated no differential change in readmissions among moderate and high Medicare bed share hospitals. CONCLUSIONS: HRRP penalties were not associated with any change in readmissions rate. The CMS should consider alternative options - including working collaboratively with hospitals - to reduce readmissions.},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{woolhandler_public_2021,

title = {Public policy and health in the Trump era.},

author = {Steffie Woolhandler and David U. Himmelstein and Sameer Ahmed and Zinzi Bailey and Mary T. Bassett and Michael Bird and Jacob Bor and David Bor and Olveen Carrasquillo and Merlin Chowkwanyun and Samuel L. Dickman and Samantha Fisher and Adam Gaffney and Sandro Galea and Richard N. Gottfried and Kevin Grumbach and Gordon Guyatt and Helena Hansen and Philip J. Landrigan and Michael Lighty and Martin McKee and Danny McCormick and Alecia McGregor and Reza Mirza and Juliana E. Morris and Joia S. Mukherjee and Marion Nestle and Linda Prine and Altaf Saadi and Davida Schiff and Martin Shapiro and Lello Tesema and Atheendar Venkataramani},

doi = {10.1016/S0140-6736(20)32545-9},

issn = {1474-547X 0140-6736},

year  = {2021},

date = {2021-02-01},

journal = {Lancet (London, England)},

volume = {397},

number = {10275},

pages = {705–753},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{lines_states_2021,

title = {States' Performance in Reducing Uninsurance Among Black, Hispanic, and Low-Income Americans Following Implementation of the Affordable Care Act.},

author = {Gregory Lines and Kira Mengistu and Megan Rose Carr LaPorte and Deborah Lee and Lynn Anderson and Daniel Novinson and Erica Dwyer and Sonja Grigg and Hugo Torres and Gaurab Basu and Danny McCormick},

doi = {10.1089/heq.2020.0102},

issn = {2473-1242},

year  = {2021},

date = {2021-01-01},

journal = {Health equity},

volume = {5},

number = {1},

pages = {493–502},

abstract = {Purpose: To assess state-level variation in changes in uninsurance among Black, Hispanic, and low-income Americans after implementation of the Affordable Care Act (ACA). Methods: We analyzed data from the Behavioral Risk Factor Surveillance System from 2012 to 2016, excluding 2014. For Black, Hispanic, and low-income (<$35,000/year) adults 18-64 years of age, we estimated multivariable regression adjusted pre- (2012-2013) to post-ACA (2015-2016) percentage point changes in uninsurance for each U.S. state. We compared absolute and relative changes and the proportion remaining uninsured post-ACA across states. We also examined whether state-level variation in coverage gains was associated with changes in forgoing needed care due to cost. Results: The range in the percentage point reduction in uninsurance varied substantially across states: 19-fold for Black (0.9-17.4), 18-fold for Hispanic (1.2-21.5), and 23-fold for low-income (1.0-27.8) adults. State-level variation in changes in uninsurance relative to baseline uninsurance rates also varied substantially. In some states, more than one quarter of Black, one half of Hispanic, and approaching one half of low-income adults remained uninsured after full implementation of the ACA. Compared with states in the lowest quintile of change in coverage, states in the highest quintile experienced greater improvements in ability to see a physician. Conclusions: Performance on reducing uninsurance for Black, Hispanic, and low-income Americans under the ACA varied substantially among U.S. states with some making substantial progress and others making little. Post-ACA uninsurance rates remained high for these populations in many states.},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{jeurissen_for-profit_2021,

title = {For-Profit Hospitals Have Thrived Because of Generous Public Reimbursement Schemes, Not Greater Efficiency: A Multi-Country Case Study.},

author = {Patrick P. T. Jeurissen and Florien M. Kruse and Reinhard Busse and David U. Himmelstein and Elias Mossialos and Steffie Woolhandler},

doi = {10.1177/0020731420966976},

issn = {1541-4469 0020-7314},

year  = {2021},

date = {2021-01-01},

journal = {International journal of health services : planning, administration, evaluation},

volume = {51},

number = {1},

pages = {67–89},

abstract = {For-profit hospitals' market share has increased in many nations over recent decades. Previous studies suggest that their growth is not attributable to superior performance on access, quality of care, or efficiency. We analyzed other factors that we hypothesized may contribute to the increasing role of for-profit hospitals. We studied the historical development of the for-profit hospital sector across 4 nations with contrasting trends in for-profit hospital market share: the United States, the United Kingdom, Germany, and the Netherlands. We focused on 3 factors that we believed might help explain why the role of for-profits grew in some nations but not in others: (1) the treatment of for-profits by public reimbursement plans, (2) physicians' financial interests, and (3) the effect of the political environment. We conclude that access to subsidies and reimbursement under favorable terms from public health care payors is an important factor in the rise of for-profit hospitals. Arrangements that aligned financial incentives of physicians with the interests of for-profit hospitals were important in stimulating for-profit growth in an earlier era, but they play little role at present. Remarkably, the environment for for-profit ownership seems to have been largely immune to political shifts.},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{wong_sgims_2021,

title = {SGIM's Endorsement of ACP's Better Is Possible: Aligning Policy with Values.},

author = {Christopher J. Wong and Steffie Woolhandler and David U. Himmelstein and Danny McCormick},

doi = {10.1007/s11606-020-06312-0},

issn = {1525-1497 0884-8734},

year  = {2021},

date = {2021-01-01},

journal = {Journal of general internal medicine},

volume = {36},

number = {1},

pages = {203–204},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{sehgal_feasibility_2021,

title = {Feasibility of Separate Rooms for Home Isolation and Quarantine for COVID-19 in the United States.},

author = {Ashwini R. Sehgal and David U. Himmelstein and Steffie Woolhandler},

doi = {10.7326/M20-4331},

issn = {1539-3704 0003-4819},

year  = {2021},

date = {2021-01-01},

journal = {Annals of internal medicine},

volume = {174},

number = {1},

pages = {127–129},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{gaffney_pricing_2021,

title = {Pricing Universal Health Care: How Much Would The Use Of Medical Care Rise?},

author = {Adam Gaffney and David U. Himmelstein and Steffie Woolhandler and James G. Kahn},

doi = {10.1377/hlthaff.2020.01715},

issn = {2694-233X 0278-2715},

year  = {2021},

date = {2021-01-01},

journal = {Health affairs (Project Hope)},

volume = {40},

number = {1},

pages = {105–112},

abstract = {The return of a Democratic administration to the White House, coupled with coronavirus disease 2019 (COVID-19) pandemic-induced contractions of job-based insurance, may reignite debate over public coverage expansion and its costs. Decades of research demonstrate that uninsured people and people with copays and deductibles use less care than people with first-dollar coverage. Hence, most economic analyses of Medicare for All proposals and other coverage expansions project increased utilization and associated costs. We review the utilization surges that such analyses have predicted and contrast them with the more modest utilization increments observed after past coverage expansions in the US and other affluent nations. The discrepancy between predicted and observed utilization changes suggests that analysts underestimate the role of supply-side constraints-for example, the finite number of physicians and hospital beds. Our review of the utilization effects of past coverage expansions suggests that a first-dollar universal coverage expansion would increase ambulatory visits by 7-10 percent and hospital use by 0-3 percent. Modest administrative savings could offset the costs of such increases.},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{gaffney_illness-related_2020,

title = {Illness-Related Work Absence in Mid-April Was Highest on Record.},

author = {Adam W. Gaffney and David U. Himmelstein and Steffie Woolhandler},

doi = {10.1001/jamainternmed.2020.2926},

issn = {2168-6114 2168-6106},

year  = {2020},

date = {2020-12-01},

journal = {JAMA internal medicine},

volume = {180},

number = {12},

pages = {1699–1701},

abstract = {This survey study analyzes data from the Current Population Survey to compare trends in work absence over the first 4 months of 2020 relative to 2019 to shed light on the health and ecenomic effects of the coronavirus disease 2019 pandemic.},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{gaffney_home_2020,

title = {Home Sick with Coronavirus Symptoms: a National Study, April-May 2020.},

author = {Adam W. Gaffney and David Himmelstein and David Bor and Danny McCormick and Steffie Woolhandler},

doi = {10.1007/s11606-020-06159-5},

issn = {1525-1497 0884-8734},

year  = {2020},

date = {2020-11-01},

journal = {Journal of general internal medicine},

volume = {35},

number = {11},

pages = {3409–3412},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{gaffney_risk_2020,

title = {Risk for Severe COVID-19 Illness Among Teachers and Adults Living With School-Aged Children.},

author = {Adam W. Gaffney and David Himmelstein and Steffie Woolhandler},

doi = {10.7326/M20-5413},

issn = {1539-3704 0003-4819},

year  = {2020},

date = {2020-11-01},

journal = {Annals of internal medicine},

volume = {173},

number = {9},

pages = {765–767},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{gaffney_health_2020,

title = {Health and Social Precarity Among Americans Receiving Unemployment Benefits During the COVID-19 Outbreak.},

author = {Adam W. Gaffney and David U. Himmelstein and Danny McCormick and Steffie Woolhandler},

doi = {10.1007/s11606-020-06207-0},

issn = {1525-1497 0884-8734},

year  = {2020},

date = {2020-11-01},

journal = {Journal of general internal medicine},

volume = {35},

number = {11},

pages = {3416–3419},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{progovac_understanding_2020,

title = {Understanding the Role of Past Health Care Discrimination in Help-Seeking and Shared Decision-Making for Depression Treatment Preferences.},

author = {Ana M. Progovac and Dharma E. Cortés and Valeria Chambers and Jonathan Delman and Deborah Delman and Danny McCormick and Esther Lee and Selma De Castro and María José Sánchez Román and Natasha A. Kaushal and Timothy B. Creedon and Rajan A. Sonik and Catherine Rodriguez Quinerly and Caryn R. R. Rodgers and Leslie B. Adams and Ora Nakash and Afsaneh Moradi and Heba Abolaban and Tali Flomenhoft and Ruth Nabisere and Ziva Mann and Sherry Shu-Yeu Hou and Farah N. Shaikh and Michael Flores and Dierdre Jordan and Nicholas J. Carson and Adam C. Carle and Frederick Lu and Nathaniel M. Tran and Margo Moyer and Benjamin L. Cook},

doi = {10.1177/1049732320937663},

issn = {1049-7323},

year  = {2020},

date = {2020-10-01},

journal = {Qualitative health research},

volume = {30},

number = {12},

pages = {1833–1850},

abstract = {As a part of a larger, mixed-methods research study, we conducted semi-structured interviews with 21 adults with depressive symptoms to understand the role that past health care discrimination plays in shaping help-seeking for depression treatment and receiving preferred treatment modalities. We recruited to achieve heterogeneity of racial/ethnic backgrounds and history of health care discrimination in our participant sample. Participants were Hispanic/Latino (n = 4), non-Hispanic/Latino Black (n = 8), or non-Hispanic/Latino White (n = 9). Twelve reported health care discrimination due to race/ethnicity, language, perceived social class, and/or mental health diagnosis. Health care discrimination exacerbated barriers to initiating and continuing depression treatment among patients from diverse backgrounds or with stigmatized mental health conditions. Treatment preferences emerged as fluid and shaped by shared decisions made within a trustworthy patient-provider relationship. However, patients who had experienced health care discrimination faced greater challenges to forming trusting relationships with providers and thus engaging in shared decision-making processes.},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{himmelstein_us_2020,

title = {The UṠ. Health Care System on the Eve of the Covid-19 Epidemic: A Summary of Recent Evidence on Its Impaired Performance.},

author = {David U. Himmelstein and Steffie Woolhandler},

doi = {10.1177/0020731420937631},

issn = {1541-4469 0020-7314},

year  = {2020},

date = {2020-10-01},

journal = {International journal of health services : planning, administration, evaluation},

volume = {50},

number = {4},

pages = {408–414},

abstract = {Four decades of neoliberal health policies have left the United States with a health care system that prioritizes the profits of large corporate actors, denies needed care to tens of millions, is extraordinarily fragmented and inefficient, and was ill prepared to address the COVID-19 pandemic. The payment system has long rewarded hospitals for providing elective surgical procedures to well-insured patients while penalizing those providing the most essential and urgent services, causing hospital revenues to plummet as elective procedures were cancelled during the pandemic. Before the recession caused by the pandemic, tens of millions of Americans were unable to afford care, compromising their physical and financial health; deep-pocketed corporate interests were increasingly dominating the hospital industry and taking over physicians' practices; and insurers' profits hit record levels. Meanwhile, yawning class-based and racial inequities in care and health outcomes remain and have even widened. Recent data highlight the failure of policy strategies based on market models and the need to shift to a nonprofit social insurance model.},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{himmelstein_health_2020,

title = {Health Insurance Status and Risk Factors for Poor Outcomes With COVID-19 Among UṠ. Health Care Workers: A Cross-Sectional Study.},

author = {David U. Himmelstein and Steffie Woolhandler},

doi = {10.7326/M20-1874},

issn = {1539-3704 0003-4819},

year  = {2020},

date = {2020-09-01},

journal = {Annals of internal medicine},

volume = {173},

number = {5},

pages = {410–412},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{hawks_health_2020,

title = {Health Status and Health Care Utilization of US Adults Under Probation: 2015-2018.},

author = {Laura Hawks and Emily A. Wang and Benjamin Howell and Steffie Woolhandler and David U. Himmelstein and David Bor and Danny McCormick},

doi = {10.2105/AJPH.2020.305777},

issn = {1541-0048 0090-0036},

year  = {2020},

date = {2020-09-01},

journal = {American journal of public health},

volume = {110},

number = {9},

pages = {1411–1417},

abstract = {Objectives. To compare the health and health care utilization of persons on and not on probation nationally.Methods. Using the National Survey of Drug Use and Health, a population-based sample of US adults, we compared physical, mental, and substance use disorders and the use of health services of persons (aged 18-49 years) on and not on probation using logistic regression models controlling for age, race/ethnicity, gender, poverty, and insurance status.Results. Those on probation were more likely to have a physical condition (adjusted odds ratio [AOR] = 1.3; 95% confidence interval [CI] = 1.2, 1.4), mental illness (AOR = 2.4; 95% CI = 2.1, 2.8), or substance use disorder (AOR = 4.2; 95% CI = 3.8, 4.5). They were less likely to attend an outpatient visit (AOR = 0.8; 95% CI = 0.7, 0.9) but more likely to have an emergency department visit (AOR = 1.8; 95% CI = 1.6, 2.0) or hospitalization (AOR = 1.7; 95% CI = 1.5, 1.9).Conclusions. Persons on probation have an increased burden of disease and receive less outpatient care but more acute services than persons not on probation.Public Health Implications. Efforts to address the health needs of those with criminal justice involvement should include those on probation.},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{gaffney_182_2020,

title = {18.2 Million Individuals at Increased Risk of Severe COVID-19 Illness Are Un- or Underinsured.},

author = {Adam W. Gaffney and Laura Hawks and David H. Bor and Steffie Woolhandler and David U. Himmelstein and Danny McCormick},

doi = {10.1007/s11606-020-05899-8},

issn = {1525-1497 0884-8734},

year  = {2020},

date = {2020-08-01},

journal = {Journal of general internal medicine},

volume = {35},

number = {8},

pages = {2487–2489},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{hawks_covid-19_2020,

title = {COVID-19 in Prisons and Jails in the United States.},

author = {Laura Hawks and Steffie Woolhandler and Danny McCormick},

doi = {10.1001/jamainternmed.2020.1856},

issn = {2168-6114 2168-6106},

year  = {2020},

date = {2020-08-01},

journal = {JAMA internal medicine},

volume = {180},

number = {8},

pages = {1041–1042},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{gaffney_effect_2020,

title = {The Effect of Large-scale Health Coverage Expansions in Wealthy Nations on Society-Wide Healthcare Utilization.},

author = {Adam Gaffney and Steffie Woolhandler and David Himmelstein},

doi = {10.1007/s11606-019-05529-y},

issn = {1525-1497 0884-8734},

year  = {2020},

date = {2020-08-01},

journal = {Journal of general internal medicine},

volume = {35},

number = {8},

pages = {2406–2417},

abstract = {Most analysts project that a reform like Medicare-for-All that lowers financial barriers to care would cause a surge in the utilization of services, raising costs despite stable or even reduced prices. However, the finite supply of physicians and hospital beds could constrain such utilization increases. We reviewed the effects of 13 universal coverage expansions in capitalist nations on physician and hospital utilization, beginning with New Zealand's 1938 Social Security Act up through the 2010 Affordable Care Act in the USA. Almost all coverage expansions had either a small (i.e., < 10%) or no effect on society-wide utilization. However, coverage expansions often redistributed care-increasing use among newly covered groups while producing small, offsetting reductions among those already covered. We conclude that in wealthy nations, large-scale coverage expansions need not cause overall utilization to surge if provider supply is controlled. However, such reforms could redirect care towards patients who most need it.},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{gaffney_us_2020,

title = {US law enforcement crowd control tactics at anti-racism protests: a public health threat.},

author = {Adam W. Gaffney and Danny McCormick and Steffie Woolhandler and David U. Himmelstein},

doi = {10.1016/S0140-6736(20)31421-5},

issn = {1474-547X 0140-6736},

year  = {2020},

date = {2020-07-01},

journal = {Lancet (London, England)},

volume = {396},

number = {10243},

pages = {21},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{basu_lessons_2020,

title = {Lessons from a social medicine and advocacy curriculum.},

author = {Gaurab Basu and Eileen M. Dryden and Richard J. Pels and Rachel L. Stark and Priyank Jain and David H. Bor and Amy M. Sullivan and Danny McCormick},

doi = {10.1111/medu.14114},

issn = {1365-2923 0308-0110},

year  = {2020},

date = {2020-05-01},

journal = {Medical education},

volume = {54},

number = {5},

pages = {466},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{hawks_trends_2020,

title = {Trends in Unmet Need for Physician and Preventive Services in the United States, 1998-2017.},

author = {Laura Hawks and David U. Himmelstein and Steffie Woolhandler and David H. Bor and Adam Gaffney and Danny McCormick},

doi = {10.1001/jamainternmed.2019.6538},

issn = {2168-6114 2168-6106},

year  = {2020},

date = {2020-03-01},

journal = {JAMA internal medicine},

volume = {180},

number = {3},

pages = {439–448},

abstract = {IMPORTANCE: Improvements in insurance coverage and access to care have resulted from the Affordable Care Act (ACA). However, a focus on short-term pre- to post-ACA changes may distract attention from longer-term trends in unmet health needs, and the problems that persist. OBJECTIVE: To identify changes from 1998 to 2017 in unmet need for physician services among insured and uninsured adults aged 18 to 64 years in the United States. DESIGN, SETTING, AND PARTICIPANTS: Survey study using 20 years of data, from January 1, 1998, to December 31, 2017, from the Centers for Disease Control and Prevention Behavioral Risk Factor Surveillance System to identify trends in unmet need for physician and preventive services. MAIN OUTCOMES AND MEASURES: The proportion of persons unable to see a physician when needed owing to cost (in the past year), having no routine checkup for those in whom a routine checkup was likely indicated (within 2 years), or failing to receive clinically indicated preventive services (in the recommended timeframe), overall and among subgroups defined by the presence of chronic illnesses and by self-reported health status. We estimated changes over time using logistic regression controlling for age, sex, race, Census region, employment status, and income. RESULTS: Among the adults aged 18 to 64 years in 1998 (n = 117 392) and in 2017 (n = 282 378) who responded to the Centers for Disease Control and Prevention Behavioral Risk Factors Surveillance System (mean age was 39.2 [95% CI, 39.0-39.3]; 50.3% were female; 65.9% were white), uninsurance decreased by 2.1 (95% CI, 1.6-2.5) percentage points (from 16.9% to 14.8%). However, the adjusted proportion unable to see a physician owing to cost increased by 2.7 (95% CI, 2.2-3.8) percentage points overall (from 11.4% to 15.7%, unadjusted); by 5.9 (95% CI, 4.1-7.8) percentage points among the uninsured (32.9% to 39.6%, unadjusted) and 3.6 (95% CI, 3.2-4.0) percentage points among the insured (from 7.1% to 11.5%, unadjusted). The adjusted proportion of persons with chronic medical conditions who were unable to see a physician because of cost also increased for most conditions. For example, an increase in the inability to see a physician because of cost for patients with cardiovascular disease was 5.9% (95% CI, 1.7%-10.1%), for patients with elevated cholesterol was 3.5% (95% CI, 2.5%-4.5%), and for patients with binge drinking was 3.1% (95% CI, 2.3%-3.3%). The adjusted proportion of chronically ill adults receiving checkups did not change. While the adjusted share of people receiving guideline-recommended cholesterol tests (16.8% [95% CI, 16.1%-17.4%]) and flu shots (13.2% [95% CI, 12.7%-13.8%]) increased, the proportion of women receiving mammograms decreased (-6.7% [95% CI, -7.8 to -5.5]). CONCLUSIONS AND RELEVANCE: Despite coverage gains since 1998, most measures of unmet need for physician services have shown no improvement, and financial access to physician services has decreased.},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{gaffney_illness_2020,

title = {Illness should not inflict financial ruin.},

author = {Adam Gaffney},

doi = {10.1136/bmj.m327},

issn = {1756-1833 0959-8138},

year  = {2020},

date = {2020-02-01},

journal = {BMJ (Clinical research ed.)},

volume = {368},

pages = {m327},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{woolhandler_american_2020,

title = {The American College of Physicians' Endorsement of Single-Payer Reform: A Sea Change for the Medical Profession.},

author = {Steffie Woolhandler and David U. Himmelstein},

doi = {10.7326/M19-3775},

issn = {1539-3704 0003-4819},

year  = {2020},

date = {2020-01-01},

journal = {Annals of internal medicine},

volume = {172},

number = {2 Suppl},

pages = {S60–S61},

keywords = {},

pubstate = {published},

tppubtype = {article}

}

@article{himmelstein_health_2020-1,

title = {Health Care Administrative Costs in the United States and Canada, 2017.},

author = {David U. Himmelstein and Terry Campbell and Steffie Woolhandler},

doi = {10.7326/M19-2818},

issn = {1539-3704 0003-4819},

year  = {2020},

date = {2020-01-01},

journal = {Annals of internal medicine},

volume = {172},

number = {2},

pages = {134–142},

abstract = {BACKGROUND: Before Canada's single-payer reform, its payment system, health costs, and number of health administrative personnel per capita resembled those of the United States. By 1999, administration accounted for 31% of U.S. health expenditures versus 16.7% in Canada. No recent comprehensive analyses of those costs are available. OBJECTIVE: To quantify 2017 spending for administration by insurers and providers. DESIGN: Analyses of government reports, accounting data that providers file with regulators, surveys of physicians, and census-collected data on employment in health care. SETTING: United States and Canada. MEASUREMENTS: Insurance overhead; administrative expenditures of hospitals, physicians, nursing homes, home care agencies, and hospices. RESULTS: U.S. insurers and providers spent $812 billion on administration, amounting to $2497 per capita (34.2% of national health expenditures) versus $551 per capita (17.0%) in Canada: $844 versus $146 on insurers' overhead; $933 versus $196 for hospital administration; $255 versus $123 for nursing home, home care, and hospice administration; and $465 versus $87 for physicians' insurance-related costs. Of the 3.2-percentage point increase in administration's share of U.S. health expenditures since 1999, 2.4 percentage points was due to growth in private insurers' overhead, mostly because of high overhead in their Medicare and Medicaid managed-care plans. LIMITATIONS: Estimates exclude dentists, pharmacies, and some other providers; accounting categories for the 2 countries differ somewhat; and methodological changes probably resulted in an underestimate of administrative cost growth since 1999. CONCLUSION: The gap in health administrative spending between the United States and Canada is large and widening, and it apparently reflects the inefficiencies of the U.S. private insurance-based, multipayer system. The prices that U.S. medical providers charge incorporate a hidden surcharge to cover their costly administrative burden. PRIMARY FUNDING SOURCE: None.},

keywords = {},

pubstate = {published},

tppubtype = {article}

}